Prior authorization codes

Capital District Physicians' Health Plan, Inc. (CDPHP)

Active CPT codes that appear on the extracted prior authorization list for this health plan.

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CodeProcedure / ServiceEffectiveRevisedConfidenceSource
00001
multicentre, phase 3 trial. Lancet Neurol. 2021 Apr;20(4):284-293. doi: 10.1016/ -4422(21) -6
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
00005
Institute-Penn Medicine Evidence-based Practice Center under Contract No. HHSA 290-2015- -I)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
00006
o Obstructive Sleep Apnea: Diagnosis and Treatment, 1370/20
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
00007
Butchbach. Available at: http://journal.frontiersin.org/article/10.3389/fmolb.2016. /full. Accessed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0001U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
00020
October 2000
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0002U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0003U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
00040
https://www.nature.com/articles/d41573-022- -2
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
00045
(Psychiatric): 1370/20
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
00049
9. Actinic Keratoses Treatment (#CAG- ; Health Care Finance Administration
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0004M
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
00056
review. Eur Urol Focus. 2021 Mar 1: -4569(21) -0
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0005U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
00063
Mar;22(1):e2017. . PMID:29398898
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0006M
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0007M
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0007U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0008U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0009U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0010U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0011M
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0011U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0012M
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0013M
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0016M
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0016U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0017M
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0017U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0018M
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0018U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0019U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0020M
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0021U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0022U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0023U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
00241
multicenter trial. The Lancet: Neurology. 2021;20(12)1012-1026. doi:10.1016/s1474-4422(21) -6
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0024U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0025U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0026U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0027U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0029U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0030U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0031U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
00327
https://www.jvascsurg.org/article/ -5214(11) -2/pdf
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0032U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0034U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0035U
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0036U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0037U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0038U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0039U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0040U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0041U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0042T
• CT cerebral perfusion analysis
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0042U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0043U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0044U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
00450
reimbursement for electroconvulsive therapy. OEI-12-01- . Washington, DC; U.S. Department of
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0045U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0046U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0047U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
00487
pdf
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0048U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0049U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0050U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0051U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0052U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0054U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
00552
16. Division of Managed Care Response to Coverage Question. Reference number: MA
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0055U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
00562
Diabetes Management System, Reference number: MA- , 7/22/10
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0058T
Removed termed code and replaced with
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0058U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0059U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0060U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0061U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
00626
https://www.nature.com/articles/d43747-020- -y
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0062U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0063U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0064T
Uterine transplant
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0064U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0065T
Uterine transplant
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0065U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
00661
https://doi.org/10.1038/s41581-022- -1
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0066T
Uterine transplant
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0067T
Uterine transplant
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0067U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
00682
Therapy. Transplant Cell Ther. 2024 Sep 20: -6367(24) -1
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0068T
Uterine transplant
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0068U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0069T
Uterine transplant
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0069U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0070U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0071T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0071U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0072T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0072U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0073U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0074U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0075T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0075U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0076T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0076U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0077U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0078U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0079U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0080U
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0082U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0083U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0084U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0086U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0087U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0088U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0089U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0090U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0091U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0092U
Not Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0093U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0094U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0095U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0096U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
01001
http://content.onlinejacc.org/data/Journals/JAC/ / .pdf
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0101T
Extracorporeal Shock Wave Treatment ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0101U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0102T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0102U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0103U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0105U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0106U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0107U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0108U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0109U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0110U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0111U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0112U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0113U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0114U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0115U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0116U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0117U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0118U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0119U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0120U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0121U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0122U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0123U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0126T
Removed termed code and replaced with
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0129U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0130U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0133U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0134U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
01353
4
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0136U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0137U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0138U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
01405
Journal Jan 2018. https://erj.ersjournals.com/content/erj/early/2018/10/25/13993003
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0140U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0141U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0142U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0152U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0153U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0154U
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trial. Lancet. 2023;402( ):1449-1458. doi:10.1016/ -6736(23) -0
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[PDF] CDPHP Policies List - AWS
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0165U
(E/I) Peanut allergen-specific quantitative assessment of multiple epitopes using
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[PDF] CDPHP Policies List - AWS
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(E/I) Peanut allergen-specific quantitative assessment of multiple epitopes using
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8. Kang C. Lumasiran: A Review in Primary Hyperoxaluria Type 1. Drugs. 2024 Jan 22. doi: 10.1007/s40265-023- -1. 3/2024
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expanded access. Lancet. 2022 Jan 22;399( ):372-383. doi: 10.1016/ -6736(21) -1. PMID
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Vyvgart (efgartigimod) Prescribing information, Argenx US, Inc., Boston, MA . Revised 12/2021. 8/2024 8/2024
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6 Aqvesme (mitapivat) prescribing information. Agios Pharmaceuticals, Inc. Cambridge, MA 12/2025 2/2026
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2 Xenpozyme prescribing information, Genzyme Corporation, Cambridge, MA . 12/23 9/24
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17 Tysabri prescribing information, Biogen Idec Inc., Cambridge, MA . 10/23 11/24
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9 Skysona prescribing information, Bluebird Bio, Inc., Somerville, MA . 8/2025 8/2025
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6 Casgevy prescribing information, Vertex Pharmaceuticals Incorporated, Boston, MA . Revised 9/2025 Oct 2025
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Lexington, MA . Revised 06/24
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0272U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0273T
Removed deleted codes , , and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0273U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0274T
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0274U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0275T
10/28/2025 Added Renal Denervation for Uncontrolled Hypertension and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0275U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0276U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0277U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0278T
Required Not Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0278U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0279U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0280U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0281U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0282U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0283U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0284U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0285U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0286U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0287U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0288U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0289U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0290U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0291U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0292U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0293U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0294U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0295U
Required Required Not Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0296U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0297U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0298U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0299U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0300U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0301U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0302U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0303U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0304U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0305U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0306U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0307U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0308U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0309U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0310U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0311U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0312T
4/1/2023 • Removed termed vagus nerve blocking therapy codes ( ) from
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0312U
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0313T
4/1/2023 • Removed termed vagus nerve blocking therapy codes ( ) from
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0313U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0314T
4/1/2023 • Removed termed vagus nerve blocking therapy codes ( ) from
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0314U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0315T
4/1/2023 • Removed termed vagus nerve blocking therapy codes ( ) from
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0315U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0316T
4/1/2023 • Removed termed vagus nerve blocking therapy codes ( ) from
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0316U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0317T
4/1/2023 • Removed termed vagus nerve blocking therapy codes ( ) from
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0317U
Required Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0318U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0319U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0320U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0321U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0322U
Required Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0323U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0326U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0327U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0328U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0329U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0330U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0331T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0331U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0332T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0332U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0333T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0333U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0334U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0335T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0335U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0336U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0337U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0338T
Not Required Not Required Not Required Not Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0338U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0339T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0339U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0340U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0341U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0342T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0342U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0343U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0344U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0345T
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0345U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0347U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0348U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0349U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0350U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0351U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0352U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0355U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0356T
11/11/20 Removed codes for the insertion of drug-eluting implant ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0356U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0358T
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0358U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0359U
Required Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0360U
Required Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0361U
Required Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0362U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0363U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0364U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0365U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0366U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0367U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0368U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0371U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0372U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0375U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0376T
Removed from exclusions codes and as these are
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0376U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0377U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0378U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0379T
Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0379U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0380U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0381U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0382U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0383U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0384U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0385U
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0387U
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0388U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0389U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0390U
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0391U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0392U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0393U
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0394T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0394U
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0395T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0395U
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0396U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0397T
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0398U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0399U
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0400U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0401U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0402U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0403T
Diabetes Prevention Program ( , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0403U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0404T
Removed termed code and replaced it with new code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0404U
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0405U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0406U
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0407U
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0408T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0408U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0409T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0409U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0410T
Cardiac Contractility Modulation (CCM) for Heart Failure
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0410U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0411T
Cardiac Contractility Modulation (CCM) for Heart Failure
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0411U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0412U
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0413U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0414U
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0415U
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0417T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0417U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0418T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0418U
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0419U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0420U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0421T
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0421U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0422U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0423U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0424U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0425U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0426U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0433U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0434U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0437T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0437U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0438U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0439T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0439U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0440T
Ablation, percutaneous, cryoablation Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0440U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0441T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0442T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0444U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0446T
Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0447T
Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0448T
Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0449T
) are considered medically necessary for any of the following indications
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0449U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0450T
Removed from exclusions codes and as these are
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0452U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0453U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0454U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0455U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0456U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0460U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0461U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0462U
Required Not Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0463U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0465U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0466T
Effective 01/01/2022: Removed deleted codes -04668T
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0466U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0467U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0469U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0471U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0473U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0474T
• CyPass microstent ( , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0474U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0475U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0476U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0477U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0478U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0479T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0480T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0480U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0481U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0483T
Not Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0484T
Not Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0485U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0486U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0487U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0488T
Diabetes Prevention Program ( , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0488U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0489U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0493U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0494U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0495U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0496U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0497U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0498U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0499U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0500T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0500U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0501T
1/1/2024 Deleted termed codes and replaced with new code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0501U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0502T
1/1/2024 Deleted termed codes and replaced with new code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0502U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0503T
1/1/2024 Deleted termed codes and replaced with new code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0504T
1/1/2024 Deleted termed codes and replaced with new code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0504U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0505U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0506U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0507U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0510U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0512U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0513U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0515T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0516T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0516U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0517T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0519T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0520T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0523T
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0523U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0525T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0529U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0530U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0532U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0533U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0534U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0536U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0537U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0538U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0539U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0540U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0543U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0544T
Not Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0545T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0549U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0552T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0558U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0559U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0568U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0569T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0570T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0570U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0571T
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0572T
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0573T
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0573U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0574T
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0574U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0575T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0575U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0576T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0576U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0577T
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0578T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0578U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0579T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0580T
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0582T
Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0582U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0583U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0584T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0585T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0585U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0586T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0586U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0587T
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0588T
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0589T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0590T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0591U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0592U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0594T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0596T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0596U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0597T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0597U
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0598T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0599U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0600T
Required Required Not Required Not Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0601T
Not Required Required Not Required Not Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0602U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0605U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0607T
Required Not Required Required Required Not Required Not Required
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[PDF] CDPHP Policies List - AWS
0608T
Required Required Required Required Not Required Not Required
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[PDF] CDPHP Policies List - AWS
0609T
Required Required Required Required Required Required
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[PDF] CDPHP Policies List - AWS
0609U
Required Required Required Required Required Required
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[PDF] CDPHP Policies List - AWS
0610T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0611T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0611U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0612T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0612U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0613U
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0614T
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0615T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0619T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0620T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0623T
Required Required Required Required Required Required
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[PDF] CDPHP Policies List - AWS
0624T
Required Required Required Required Required Required
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[PDF] CDPHP Policies List - AWS
0625T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0626T
Required Required Required Required Required Required
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[PDF] CDPHP Policies List - AWS
0627T
Required Required Required Required Required Required
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[PDF] CDPHP Policies List - AWS
0628T
Required Required Required Required Required Required
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[PDF] CDPHP Policies List - AWS
0629T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0630T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0631T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0632T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0633T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0634T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0635T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0636T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0637T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0638T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0639T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0640T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0644T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0645T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0646T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0647T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0648T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0649T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0651T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0652T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0653T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0654T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0655T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0656T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0657T
Required Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0658T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0659T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0662T
Required Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0663T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0664T
Uterine Transplantation , , Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0665T
Uterine Transplantation , , Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0666T
unproven
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0667T
unproven
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[PDF] CDPHP Policies List - AWS
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0670T
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[PDF] CDPHP Policies List - AWS
0669T
0670T
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0670T
Vagus nerve stimulation (VNS) 61885 VNS for treatment-resistant
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0671T
) are considered medically necessary for any of the following indications
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0672T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0673T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0683T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0684T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0685T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0686T
Required Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0687T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0688T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0689T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0690T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0691T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0692T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0693T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0694T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0695T
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0696T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0697T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0698T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0700T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0701T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0704T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0707T
Required Required Not Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0710T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0711T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0712T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0713T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0714T
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0716T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0719T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0720T
Required Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0721T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0722T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0723T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0724T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0728T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0729T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0738T
Required Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0739T
Required Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0740T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0741T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0742T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0743T
Required Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0744T
Required Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0745T
Required Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0746T
Required Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0747T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0748T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0749T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0750T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0751T
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0752T
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0753T
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0754T
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0755T
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0756T
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0757T
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0758T
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0759T
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0760T
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0761T
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0762T
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0763T
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0764T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0765T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0766T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0767T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
07701
3 Tzield [prescribing information], Provention Bio, Inc., Red Bank, NJ . 12/2023 9/2024
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0770T
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0771T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0772T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0773T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0774T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0776T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0777T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0778T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0779T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0780T
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0781T
Not Required Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0782T
Not Required Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0783T
Required Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0784T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0785T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0786T
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0788T
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0789T
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0790T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
07932
1 Mulpleta prescribing information, Shionogi Inc., Florham Park, NJ . 4/2020 9/2023
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
07936
Jersey
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0793T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0794T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0795T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0796T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0797T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0798T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0799T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0800T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0801T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0802T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0803T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0804T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0805T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0806T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0807T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0808T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0810T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0811T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0812T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0813T
(E/I) Esophagogastroduodenoscopy, flexible, transoral, with volume adjustment of
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0815T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0816T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0817T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0820T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0821T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0822T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0823T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0824T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0825T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0826T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0827T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0828T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0829T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0830T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0831T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0832T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0833T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0834T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0835T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0836T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0837T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0838T
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
0839T
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Extracorporeal Photopheresis for Bronchiolitis Obliterans Syndrome Following Lung Transplant:
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Extracorporeal Photopheresis for Bronchiolitis Obliterans Syndrome Following Lung Transplant:
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Extracorporeal Photopheresis for Bronchiolitis Obliterans Syndrome Following Lung Transplant:
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Acne (L70.0-L70.9) treatment that Acne extractions/ as an initial treatment
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• Incision and drainage ( )
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[PDF] CDPHP Policies List - AWS
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• Incision and drainage ( )
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blinded randomized trial. Can J Urol. 2020 Feb;27(1)
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blinded randomized trial. Can J Urol. 2020 Feb;27(1)
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blinded randomized trial. Can J Urol. 2020 Feb;27(1)
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blinded randomized trial. Can J Urol. 2020 Feb;27(1)
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blinded randomized trial. Can J Urol. 2020 Feb;27(1)
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blinded randomized trial. Can J Urol. 2020 Feb;27(1)
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blinded randomized trial. Can J Urol. 2020 Feb;27(1)
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trial. Lancet. 2017;390( ):849-860. doi:10.1016/ -6736(17) -8
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25. Medicare Part B Answer Book, Anesthesia Services, , 2001 Edition
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25. Medicare Part B Answer Book, Anesthesia Services, , 2001 Edition
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25. Medicare Part B Answer Book, Anesthesia Services, , 2001 Edition
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25. Medicare Part B Answer Book, Anesthesia Services, , 2001 Edition
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10205
25. Medicare Part B Answer Book, Anesthesia Services, , 2001 Edition
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10206
25. Medicare Part B Answer Book, Anesthesia Services, , 2001 Edition
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
1020T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10213
urethral lift and Rezum steam injection. Can J Urol. 2020 Jun;27(3)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10214
urethral lift and Rezum steam injection. Can J Urol. 2020 Jun;27(3)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10215
urethral lift and Rezum steam injection. Can J Urol. 2020 Jun;27(3)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10216
urethral lift and Rezum steam injection. Can J Urol. 2020 Jun;27(3)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10217
urethral lift and Rezum steam injection. Can J Urol. 2020 Jun;27(3)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10218
urethral lift and Rezum steam injection. Can J Urol. 2020 Jun;27(3)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10219
urethral lift and Rezum steam injection. Can J Urol. 2020 Jun;27(3)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
1021T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
1022T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
1023T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
1024T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10253
phase 3 trial. Lancet. 2020 Sep 12;396( ):759-769. doi: 10.1016/ -6736(20) -X. Epub
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
1025T
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10314
Cortes J, et al. Chronic myeloid leukaemia. The Lancet. 2021 Nov 20-26;398( ):1914-1926
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10322
expanded access. Lancet. 2022 Jan 22;399( ):372-383. doi: 10.1016/ -6736(21) -1. PMID
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10350
6;400( ):441-451
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10411
trial. Lancet. 2023;402( ):1449-1458. doi:10.1016/ -6736(23) -0
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10436
19. CMS Medicare Learning Network (MLN) Matters (MM) : New “K” Code for Therapeutic
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10441
25;403( ):2293-2306
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10591
6 Veopoz prescribing information, Regeneron Pharmaceuticals, Inc., Tarrytown, NY . Revised 3/24 8/25
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10646
10.1007/s00415-021- -y. Epub 2021 Jun 12. PMID: 34120208
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10960
double-blind, randomized trial in men with LUTS due to BPH. Can J Urol. 2022 Feb;29(1)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
10968
Gratzke C, et al. Prostatic urethral lift vs transurethral resection of the prostate: 2-year results of the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11021
http://www.medicare.gov/Publications/Pubs/pdf/ .pdf
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11055
Routine Foot Care ( , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11056
Routine Foot Care ( , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11057
Routine Foot Care ( , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11200
Skin tags that are asymptomatic. Skin tag removal only when repeatedly irritated
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11201
Skin tags that are asymptomatic. Skin tag removal only when repeatedly irritated
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11719
Routine Foot Care ( , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11720
Routine Foot Care ( , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11721
Routine Foot Care ( , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11730
Surgical Treatment of Nails ( , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11731
• Partial or complete avulsion ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11732
Surgical Treatment of Nails ( , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11750
Surgical Treatment of Nails ( , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11765
Surgical Treatment of Nails ( , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11914
http://www.nice.org.uk/nicemedia/live/ / / .pdf
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11920
Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11921
for the treatment of port wine stains
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11922
hemangiomas, or birth marks
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11950
Not Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11951
Not Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11952
Not Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11954
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11960
Tissue expander; insertion and/or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11970
Not Required Not Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
11971
Not Required Not Required Not Required Not Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
12110
Latham, NY
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
13239
TRAILBLAZER-ALZ 2 Randomized Clinical Trial. JAMA. 2023;330(6):512–527. doi:10.1001/jama.2023
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
13282
%2c+Inc.+( %2c+A+and+B+and+HHH+MA
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
13512
https://doi-org.gate.lib.buffalo.edu/10.1111/ctr
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
14046
https://doi.org/10.1111/hae
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
14749
[news release]. Genentech’s website. https://www.gene.com/media/press-releases/ /2018-10
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15010
purpura. J Thromb Haemost. 2020;18(10):2496-2502. doi:10.1111/jth
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15203
6 Vyjuvek prescribing information, Krystal Biotech, Inc., Pittsburgh, PA 5/2023 3/2025
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15220
Not Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15221
pattern baldness or age-related hair following surgery, trauma, infection, or other
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15271
Application of skin substitute graft to trunk, arms, legs, total wound surface area
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15272
each additional 25 sq cm wound surface area, or part thereof
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15273
Application of skin substitute graft to trunk, arms, legs, total wound surface area
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15274
each additional 100 sq cm wound surface area, or part thereof, or each additional
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15275
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15276
each additional 25 sq cm wound surface area, or part thereof
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15277
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15278
each additional 100 sq cm wound surface area, or part thereof, or each additional
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15401
8. Medicare, Part B Answer Book, “Home Care Services,” pgs. , 2002
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15402
8. Medicare, Part B Answer Book, “Home Care Services,” pgs. , 2002
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15403
8. Medicare, Part B Answer Book, “Home Care Services,” pgs. , 2002
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15771
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15772
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15775
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15776
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15777
Implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15778
Implantation of absorbable mesh or other prosthesis for delayed closure of
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15780
Required Required Not Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15781
Required Not Required Not Required Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15782
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15783
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15786
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15787
Abrasion, lesions (e.g., keratosis, Performed due to a congenital disease or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15788
Required Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15789
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15792
Required Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15793
Required Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15819
Cervicoplasty (surgery of the neck) Cervicoplasty when performed incidental to or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15820
Lower lid Blepharoplasty
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15821
Lower lid Blepharoplasty
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15822
Upper lid blepharoplasty
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15823
Upper lid blepharoplasty
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15824
Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15825
Required Not Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15826
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15828
Required Not Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15829
Required Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15830
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15832
Removed codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15833
Removed codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15834
Removed codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15835
Removed codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15836
Removed codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15837
Removed codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15838
as these are
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15839
as these are
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15847
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15876
as these are
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15877
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15878
as these are
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
15879
as these are
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
16323
AMPLATZER amulet devices in a high-risk cohort. Sci Rep. 2020 Oct 1;10(1)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
17106
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
17107
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
17108
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
17110
Acne (L70.0-L70.9) treatment that Acne extractions/ as an initial treatment
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
17111
does not meet criteria in next column. for severe acne will be considered medically
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
17340
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
17360
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
17380
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
18010
2 Kato GJ, Piel FB, Reid CD, et al. Sickle cell disease. Nat Rev Dis Primers. 2018;4: Oct 2023
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
18425
specific antibody repertoire in food allergy. Sci Rep. 2019 Dec 5;9(1)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
18688
10.1001/jama.2023. . PMID: 37768671; PMCID: PMC10540057
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19010
2. Siklos prescribing information, Medunik USA. Rosemont, PA 11/23 11/24
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19300
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19316
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19318
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19324
9/1/2021 Removed deleted CPT codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19325
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19328
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19330
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19340
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19342
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19350
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19355
Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19357
Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19361
19364
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19364
19367
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19366
9/1/2021 Removed deleted CPT codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19367
19368
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19368
19369
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19369
19380
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19370
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19371
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19380
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19396
S2066
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19406
6 Hemgenix prescribing information, CSL Behring LLC, Kankakee, IL . Revised 11/2022. Reviewed 11/22 9/23
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19499
Radiofrequency spectroscopy for Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19801
10. Medicare Part B Answer Book, Podiatric Services, pp. , 2001 edition
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19802
10. Medicare Part B Answer Book, Podiatric Services, pp. , 2001 edition
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19803
10. Medicare Part B Answer Book, Podiatric Services, pp. , 2001 edition
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19804
10. Medicare Part B Answer Book, Podiatric Services, pp. , 2001 edition
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19805
10. Medicare Part B Answer Book, Podiatric Services, pp. , 2001 edition
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
19806
10. Medicare Part B Answer Book, Podiatric Services, pp. , 2001 edition
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
20024
acute myeloid leukemia: a meta-analysis. J Natl Cancer Inst. Jan 07;96(1):38-45
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
20131
https://www.govinfo.gov/content/pkg/FR-2006-11-27/html/E6- .htm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
20526
Tendon Sheath, Ligament, Ganglion Cysts, Carpal and Tarsal Tunnel Injections (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
20550
Benefits for injection of tendons, ligaments, and bursae ( , ) are limited to three
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
20551
Benefits for injection of tendons, ligaments, and bursae ( , ) are limited to three
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
20552
Trigger Point Injections ( , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
20553
Trigger Point Injections ( , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
20560
“Dry needling” ( , ) of trigger points is considered experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
20561
“Dry needling” ( , ) of trigger points is considered experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
20600
Arthrocentesis ( , , ) is limited to three procedures every six months
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
20604
Arthrocentesis ( , , ) is limited to three procedures every six months
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
20605
Arthrocentesis ( , , ) is limited to three procedures every six months
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
20606
21485, 21490, 29800, 29804
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
20611
3. Medicare Part B Answer Book, Rehabilitation Services, pps , 2000 Edition
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
20612
)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
20878
3 Uplizna (inebilizumab-cdon) prescribing information, Viela Bio, In., Gaithersburg, MD 12/2025 2/2026
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
20999
Extracorporeal Shock Wave Treatment ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21010
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21037
aspects. Ann Transl Med. 2019;7(13)284. doi:10. /atm.2019.07.24
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21050
21485, 21490, 29800, 29804
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21060
21485, 21490, 29800, 29804
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21070
21485, 21490, 29800, 29804
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21073
21485, 21490, 29800, 29804
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21083
Impression and custom preparation of Insertion or injection of prosthetic material for
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21087
Impression and custom preparation of Insertion or injection of prosthetic material for
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21116
21485, 21490, 29800, 29804
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21120
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21121
Not Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21122
Not Required Not Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21123
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21125
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21127
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21137
Not Required Not Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21138
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21139
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21141
Removed codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21142
Not Required Not Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21143
Not Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21145
Removed codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21146
Removed codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21147
Removed codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21150
&
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21151
&
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21154
&
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21155
&
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21159
&
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21160
&
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21172
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21175
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21179
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21180
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21181
Required Not Required Required Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21182
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21183
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21184
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21188
&
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21193
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21194
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21195
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21196
&
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21198
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21240
Not Required Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21242
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21243
Not Required Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21245
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21246
Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21247
congenital disease or anomaly of a covered
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21248
from policy and PA requirement
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21249
congenital disease or anomaly of a covered
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21270
Not Required Not Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21280
Canthus repair
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21282
Canthus repair
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21480
21485, 21490, 29800, 29804
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21485
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21490
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21685
• Hyoid myotomy and suspension ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21740
Required Required Not Required Not Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21742
Required Required Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
21743
Required Required Required Not Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22206
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22207
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22210
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22212
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22214
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22220
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22222
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22224
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22505
Required Required Required Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22510
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22511
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22513
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22514
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22526
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22527
• Percutaneous intradiscal electrothermal annuloplasty [IDET] ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22532
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22533
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22548
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22551
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22554
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22556
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22558
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22586
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22590
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22595
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22600
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22610
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22612
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22630
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22633
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22800
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22802
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22804
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22808
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22810
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22812
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22818
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22819
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22836
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22837
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22838
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22849
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22850
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22852
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22855
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22856
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22857
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22860
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22861
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22862
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22864
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22865
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22867
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22868
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22869
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22870
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
22899
Endoscopic or percutaneous spinal surgical Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23031
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23035
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23040
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23044
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23100
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23101
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23107
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23120
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23125
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23130
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23140
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23145
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23146
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23150
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23155
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23156
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23170
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23172
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23174
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23180
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23182
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23184
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23190
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23195
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23200
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23210
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23220
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23296
(1)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23334
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23335
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23400
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23405
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23406
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23410
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23412
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23415
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23420
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23430
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23440
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23450
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23455
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23460
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23462
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23465
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23466
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23470
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23472
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23473
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23474
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23480
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23485
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23490
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23491
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23700
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23800
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23802
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
23929
Superior capsular reconstruction for the , Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
24289
http://content.onlinejacc.org/data/Journals/JAC/ / .pdf
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
26026
For updated guidelines, visit: https://www.guidelinecentral.com/guideline/ /#section-336178
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
26991
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
26992
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27000
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27001
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27003
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27005
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27006
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27025
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27033
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27035
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27036
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27050
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27052
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27054
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27057
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27060
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27062
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27065
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27067
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27070
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27071
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27075
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27076
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27077
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27078
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27090
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27091
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27096
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27120
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27122
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27125
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27130
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27132
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27134
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27137
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27138
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27140
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27146
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27147
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27151
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27156
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27161
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27165
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27170
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27175
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27176
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27177
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27178
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27179
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27181
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27185
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27187
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27275
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27278
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27279
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27280
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27282
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27284
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27286
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27301
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27303
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27310
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27329
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27331
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27332
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27333
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27334
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27335
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27340
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27347
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27355
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27356
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27357
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27360
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27364
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27365
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27372
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27403
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27405
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27407
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27409
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27412
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27415
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27416
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27418
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27420
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27422
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27424
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27425
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27427
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27428
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27429
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27437
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27438
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27440
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27441
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27442
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27443
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27446
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27447
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27454
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27455
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27457
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27465
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27466
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27470
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27472
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27486
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27487
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27488
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27495
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27516
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27517
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27519
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27570
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27580
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27707
2 Doptelet prescribing information. AkaRx, Inc., Durham, NC 7/2021 9/2023
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
27853
NURTURE study. Muscle Nerve. 2023 Aug;68(2):157-170. doi: 10.1002/mus. . Epub 2023 Jul
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
28529
details.aspx?LCDId= &ContrId=301&ver=96&ContrVer=1&CntrctrSelected=301*1&Cnt
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
28890
Extracorporeal Shock Wave Treatment ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
28899
any condition including, but not limited to, unproven; there is insufficient evidence
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29313
long-term management. Hepatology. 2017;66(4):1314-1322. doi:10.1002/hep
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29800
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29804
Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29805
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29806
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29807
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29819
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29820
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29821
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29822
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29823
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29824
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29825
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29827
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29828
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29850
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29851
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29855
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29856
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29860
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29861
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29862
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29863
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29866
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29867
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29868
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29870
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29871
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29873
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29874
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29875
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29876
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29877
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29879
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29880
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29881
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29882
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29883
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29884
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29885
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29886
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29887
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29888
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29889
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29914
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29915
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29916
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
29999
Superior capsular reconstruction for the , Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
30080
4. Rystiggo Prescribing Information. UCB, Inc. Smyrna, GA 3/25 7/25
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
30098
http://jcsm.aasm.org/ViewAbstract.aspx?pid=
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
30117
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
30178
2019 Sep 17. pii: -1161(19) -3
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
30400
Required Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
30410
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
30420
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
30430
Required Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
30435
Required Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
30450
Required Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
30460
Removed codes and from requiring a PA as these
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
30462
Removed codes and from requiring a PA as these
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
30468
Required Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
30469
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
30767
non-invasive tests. Am J Surg. 2020 Nov 25: -9610(20) -4
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
30801
Radiofrequency Tissue Volume Reduction Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
30999
Balloon Septoplasty Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
31231
Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
31237
Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
31242
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
31243
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
31299
Unlisted procedure, accessory sinuses (when specified as insertion of drug-eluding
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
31570
Required Not Required Not Required Not Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
31571
Required Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
31574
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
31627
Required Not Required Not Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
31660
( , ) as this procedure is also listed on the Non-Covered
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
31661
( , ) as this procedure is also listed on the Non-Covered
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
31792
phase 3 trial. Lancet. 2020 Sep 12;396( ):759-769. doi: 10.1016/ -6736(20) -X. Epub
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
31868
trial. Lancet. 2017;390( ):849-860. doi:10.1016/ -6736(17) -8
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
32851
Lung transplant, single; without cardiopulmonary bypass
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
32852
Lung transplant, single; with cardiopulmonary bypass
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
32853
Lung transplant, double (bilateral, sequential, or en bloc); without cardiopulmonary
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
32854
Lung transplant, double (bilateral, sequential, or en bloc); with cardiopulmonary
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
32855
Backbench standard preparation of cadaver donor lung allograft prior to
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
32856
Backbench standard preparation of cadaver donor lung allograft prior to
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33202
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33203
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33206
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33207
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33208
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33210
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33211
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33212
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33213
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33214
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33215
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33216
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33217
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33218
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33220
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33221
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33222
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33223
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33224
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33226
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33227
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33228
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33229
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33230
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33231
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33233
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33234
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33235
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33236
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33237
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33238
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33240
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33241
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33243
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33244
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33249
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33262
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33263
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33264
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33267
Not Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33268
Exclusion of left atrial appendage, open, performed at the time of other sternotomy
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33269
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33270
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33271
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33272
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33273
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33274
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33275
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33285
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33286
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33289
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33340
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33361
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33362
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33363
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33364
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33365
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33366
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33367
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33368
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33369
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33370
Not Required Not Required Not Required Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33394
database/view/lcd.aspx?lcdid= &ver=54&=
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33398
https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid= &ver=32&bc=0
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33399
database/view/lcd.aspx?lcdid= &ver=14&bc=0
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33418
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33419
Not Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33477
TPVR
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33611
details.aspx?LCDId= &ContrId=389
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33631
details.aspx?LCDId= &ContrId=298&ver=26&ContrVer=1&CntrctrSelected=298*1&Cnt
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33718
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33927
Total replacement heart system (artificial heart)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33928
Total replacement heart system (artificial heart)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33929
Total replacement heart system (artificial heart)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33933
Backbench standard preparation of cadaver donor heart/lung allograft prior to
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33935
Heart-lung transplant with recipient cardiectomy-pneumonectomy
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33944
Backbench standard preparation of cadaver donor heart/lung allograft prior to
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33945
Heart transplant, with or without recipient cardiectomy
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33975
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33976
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33977
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33978
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33979
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33980
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33981
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33982
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33983
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33990
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33991
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33992
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33993
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33995
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
33997
Percutaneous ventricular assist device
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
34841
Not Required Not Required Not Required Not Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
34842
Not Required Not Required Not Required Not Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
34843
Not Required Not Required Not Required Not Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
34844
Not Required Not Required Not Required Not Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
34846
Not Required Not Required Not Required Not Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
34847
Not Required Not Required Not Required Not Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
34848
Not Required Not Required Not Required Not Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
35001
details.aspx?LCDId= &ContrId=301&ver=4&ContrVer=1&CntrctrSelected=301*1&Cntr
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
35338
details.aspx?LCDId= &ContrId=301&ver=5&ContrVer=1&CntrctrSelected=301*1&Cntr
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
36465
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
36466
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
36468
Sclerotherapy for telangiectasia • Sclerotherapy as a medically necessary
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
36469
9/1/2021 Removed deleted CPT codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
36470
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
36471
Not Required Not Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
36473
• mechanochemical ablation: (i.e., , ablation therapy is limited to Medicare
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
36474
• mechanochemical ablation: (i.e., , ablation therapy is limited to Medicare
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
36482
Required Required Not Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
36483
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
36522
Not Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
37241
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
37242
Vascular embolization or occlusion, inclusive of all radiological supervision and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
37243
Vascular embolization or occlusion, inclusive of all radiological supervision and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
37244
LCD : Micro-Invasive Glaucoma Surgery (NGS)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
37262
37269
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
37269
Iontophoresis for primary focal hyperhidrosis 97033 Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
37279
POLICY NAME: NON-COVERED TECHNOLOGIES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
37788
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
37790
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
38205
Blood-derived hematopoietic progenitor cell harvesting for transplantation, per
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
38206
Blood-derived hematopoietic progenitor cell harvesting for transplantation, per
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
38210
Transplant preparation of hematopoietic progenitor cells; specific cell depletion
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
38211
tumor cell depletion
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
38212
Transplant preparation of hematopoietic progenitor cells; red blood cell removal
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
38213
Transplant preparation of hematopoietic progenitor cells; platelet depletion
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
38225
Harvesting of blood-derived T lymphocytes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
38226
Preparation for transport (e.g., cryopreservation)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
38227
Receipt and preparation of CAR-T cells
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
38228
Administration of CAR-T cells
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
38230
Bone marrow harvesting for transplantation, allogeneic
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
38232
Bone marrow harvesting for transplantation, autologous
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
38240
Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
38241
Hematopoietic progenitor cell (HPC); autologous transplantation
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
38242
Allogeneic lymphocyte infusions
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
38243
Hematopoietic progenitor cell (HPC); HPC boost
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
39036
coverage-database/view/lcd.aspx?lcdid= &ver=8&bc=0
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
39075
database/view/lcd.aspx?lcdid= &ver=7&keyword=fractional%20flow&keywordType
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
39455
database/view/lcd.aspx?lcdid= &ver=4&keyword=sacroiliac&keywordType=starts&areaId
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
39662
database/view/lcd.aspx?lcdid= &ver=5&bc=0
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
41120
**Full classification criteria may be found at: https://acrjournals.onlinelibrary.wiley.com/doi/epdf/10.1002/art
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
41512
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
41530
Not Required Required Required Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
41632
10.1002/art. . Epub 2021 Apr 23. PMID: 33474834; PMCID: PMC8169527
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
42145
• Surgical treatments
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
42299
•Injection snoreplasty ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43201
Endoscopic treatment for gastroesophageal Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43210
Not Required Not Required Not Required Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43236
System, Stretta® System, Enteryx™)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43257
therapy)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43284
Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43285
Not Required Not Required Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43290
(E/I) Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43291
(E/I) Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43497
Required Not Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43644
Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43645
with gastric bypass and small intestine reconstruction to limit absorption
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43647
*No change to • Gastric electrical stimulation (GES) or gastric pacing (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43648
*No change to • Gastric electrical stimulation (GES) or gastric pacing (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43659
effective date • Added misc. codes and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43770
Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43771
revision of adjustable gastric restrictive device component only
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43772
removal of adjustable gastric restrictive device component only
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43773
removal and replacement of adjustable gastric restrictive device component
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43774
removal of adjustable gastric restrictive device and subcutaneous port
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43775
Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43842
Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43843
other than vertical-banded gastroplasty
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43845
Gastric restrictive procedure with partial gastrectomy, pylorus-preserving
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43846
Gastric restrictive procedure, with gastric bypass for morbid obesity; with short
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43847
with small intestine reconstruction to limit absorption
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43848
Revision, open, of gastric restrictive procedure for morbid obesity, other than
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43860
Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43865
Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43881
effective date , , , , , , , ) as this is listed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43882
effective date , , , , , , , ) as this is listed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43886
Gastric restrictive procedure, open; revision of subcutaneous port component only
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43887
removal of subcutaneous port component only
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43888
removal and replacement of subcutaneous port component only
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43889
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
43999
effective date • Added misc. codes and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
44103
7 Zevaskyn prescribing information, Abeona Therapeutics Inc., Cleveland, OH . 8/2025 8/2025
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
44120
Enterectomy, resection of small intestine; single resection and anastomosis
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
44121
Enterectomy; each additional resection and anastomosis (List separately in addition
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
44125
Enterectomy, resection of small intestine; with enterostomy
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
44135
Intestinal allotransplantation from a cadaver donor
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
44136
(E/I) Intestinal allotransplantation from a living donor
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
44137
Removal of transplanted intestinal allograft, complete
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
46999
Anoscopy, with delivery of thermal energy to Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
47000
Biopsy of liver, needle; percutaneous
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
47001
Biopsy of liver, needle; when done for indicated purpose at time of other major
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
47100
Biopsy of liver, wedge
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
47133
Donor hepatectomy (including cold preservation), from cadaver donor
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
47135
Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
47140
Donor hepatectomy (including cold preservation), from living donor; left lateral
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
47141
Donor hepatectomy (including cold preservation), from living donor; total left
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
47142
Donor hepatectomy (including cold preservation), from living donor; total right
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
47143
Backbench standard preparation of cadaver donor whole liver graft prior to
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
47144
Backbench standard preparation of cadaver donor whole liver graft prior to
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
47145
Backbench standard preparation of cadaver donor whole liver graft prior to
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
47146
Backbench reconstruction of cadaver or living donor liver graft prior to
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
47147
Backbench reconstruction of cadaver or living donor liver graft prior to
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
47379
Unlisted laparoscopic procedure, liver
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
48160
Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
48552
Backbench reconstruction of cadaver donor pancreas allograft prior to
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
48554
Transplantation of pancreatic allograft
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
48556
Removal of transplanted pancreatic allograft
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49560
• Removed deleted codes , and replaced with codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49561
• Removed deleted codes , and replaced with codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49562
• Removed deleted codes , and replaced with codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49563
• Removed deleted codes , and replaced with codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49564
• Removed deleted codes , and replaced with codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49565
• Removed deleted codes , and replaced with codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49566
• Removed deleted codes , and replaced with codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49568
• Removed deleted codes , and replaced with codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49591
• Added new codes A2019-A2021 and Q4265-Q4271 to exclusions section.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49592
• Added new codes A2019-A2021 and Q4265-Q4271 to exclusions section.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49593
• Added new codes A2019-A2021 and Q4265-Q4271 to exclusions section.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49594
• Added new codes A2019-A2021 and Q4265-Q4271 to exclusions section.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49595
• Added new codes A2019-A2021 and Q4265-Q4271 to exclusions section.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49596
• Added new codes A2019-A2021 and Q4265-Q4271 to exclusions section.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49600
• Added new codes A2019-A2021 and Q4265-Q4271 to exclusions section.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49605
• Added new codes A2019-A2021 and Q4265-Q4271 to exclusions section.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49606
• Added new codes A2019-A2021 and Q4265-Q4271 to exclusions section.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49610
• Added new codes A2019-A2021 and Q4265-Q4271 to exclusions section.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49611
• Added new codes A2019-A2021 and Q4265-Q4271 to exclusions section.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49612
• Added new codes A2019-A2021 and Q4265-Q4271 to exclusions section.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49613
• Added new codes A2019-A2021 and Q4265-Q4271 to exclusions section.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49614
• Added new codes A2019-A2021 and Q4265-Q4271 to exclusions section.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49615
• Added new codes A2019-A2021 and Q4265-Q4271 to exclusions section.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49616
• Added new codes A2019-A2021 and Q4265-Q4271 to exclusions section.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49617
• Added new codes A2019-A2021 and Q4265-Q4271 to exclusions section.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
49618
• Added new codes A2019-A2021 and Q4265-Q4271 to exclusions section.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
50300
Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
50320
Donor nephrectomy (including cold preservation); open, from living donor
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
50323
Backbench standard preparation of cadaver donor renal allograft prior to
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
50325
Backbench standard preparation of living donor renal allograft (open or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
50327
Backbench reconstruction of cadaver or living donor renal allograft prior to
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
50340
Recipient nephrectomy (separate procedure)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
50360
Renal allotransplantation, implantation of graft; without recipient nephrectomy
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
50365
Renal allotransplantation, implantation of graft; with recipient nephrectomy
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
50370
Removal of transplanted renal allograft
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
50380
Renal auto-transplantation, reimplantation of kidney
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
50542
Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
50592
Required Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
50593
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
51784
• No additional benefits are available for electromyography ( , ) when
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
51785
• No additional benefits are available for electromyography ( , ) when
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
51974
details.aspx?articleId= &ver=19&ContrId=298&ContrVer=1&CntrctrSelected=298*1&Cn
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
52284
(E/I) Cystourethroscopy, with mechanical urethral dilation and urethral therapeutic drug
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
52441
Cystourethroscopy, with insertion of permanent adjustable transprostatic implant
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
52442
Cystourethroscopy, with insertion of permanent adjustable transprostatic implant
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
52443
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
52597
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
52837
details.aspx?articleId= &ver=15&Cntrctr=275
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
53032
database/view/article.aspx?articleid= &ver=118&keyword=self%20administered&keyword 9/2025
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
53451
Periurethral transperineal adjustable balloon Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
53452
continence device (e.g., ProAct, ACT unproven
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
53453
therapy systems)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
53454
Platelet-rich plasma (PRP) therapy 0232T Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
53852
Radiofrequency ablation for the treatment of Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
53854
Required Required Not Required Not Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
53860
Transurethral, radiofrequency micro- Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
53865
(E/I) Cystourethroscopy with insertion of temporary device for ischemic remodeling (ie
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
53866
(E/I) Catheterization with removal of temporary device for ischemic remodeling (ie
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
54150
Circumcision performed post-newborn Circumcision performed beyond the newborn
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
54161
Circumcision performed post-newborn Circumcision performed beyond the newborn
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
54230
• Cavernosometry or cavernosography ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
54231
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
54240
• Penile plethysmography ( ) is generally redundant clinical information and is therefore
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
54250
• Nocturnal penile tumescence and/or rigidity testing ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
54400
Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
54401
Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
54405
Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
54406
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
54408
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
54410
Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
54411
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
54415
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
54416
Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
54417
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
54660
Not Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
55400
CDPHP considers vasovasostomy and vasovasorrhaphy ( ) non-covered procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
55870
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
55874
Removed code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
55877
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
55970
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
55980
Required Required Not Required Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
56195
details.aspx?articleId= &ver=31&Cntrctr=297&ContrVer=1&CntrctrSelected=297*1&Do
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
56620
Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
58321
Intra-uterine/intra-cervical Insemination
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
58322
Intra-uterine/intra-cervical Insemination
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
58323
Intra-uterine/intra-cervical Insemination
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
58580
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
58611
http://www.nice.org.uk/nicemedia/live/ / / .pdf
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
58674
Required Required Required Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
58970
invitro-fertilization (IVF) services
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
58974
invitro-fertilization (IVF) services
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
58976
• Gamete intrafallopian transfer (GIFT) and follicle aspiration ( , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
60015
4 Zolgensma Prescribing Information, AveXis, Inc., Bannockburn, IL . 2/2025 8/2025
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
60045
1 Tepezza prescribing information, Horizon Therapeutics USA, Inc., Lake Forest, IL . Revised 1/2020. 7/23 1/25
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
60660
Radiofrequency ablation of thyroid nodule(s) / Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
60661
Radiofrequency ablation of thyroid nodule(s) / Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
61715
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
61796
Stereotactic radiosurgery
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
61797
Stereotactic radiosurgery
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
61798
Stereotactic radiosurgery
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
61799
Stereotactic radiosurgery
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
61800
Stereotactic radiosurgery
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
61885
Vagus Nerve Stimulation (VNS) for Treatment Resistant Depression (TRD)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
61886
Vagus Nerve Stimulation (VNS) for Treatment Resistant Depression (TRD)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
61888
0912T
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
61958
NDC: -2901-1
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62263
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62264
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62287
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62320
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62321
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62322
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62323
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62324
Fluoroscopic guidance ( ) is considered an integral part of the injection procedure
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62326
) and therefore, is not separately reimbursed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62327
) and therefore, is not separately reimbursed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62330
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62331
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62350
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62351
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62352
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62353
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62354
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62355
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62356
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62357
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62358
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62359
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62360
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62361
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62362
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62363
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62364
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62365
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62366
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62367
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62368
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62369
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62370
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
62380
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63001
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63003
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63005
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63011
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63012
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63015
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63016
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63017
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63020
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63030
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63032
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63040
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63042
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63045
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63046
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63047
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63050
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63051
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63055
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63056
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63064
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63075
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63077
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63081
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63085
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63087
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63090
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63101
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63102
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63185
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63190
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63191
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63200
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63250
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63251
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63252
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63300
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63301
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63302
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63303
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63304
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63305
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63306
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63307
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63620
Stereotactic radiosurgery
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63621
Stereotactic radiosurgery
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63650
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63655
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63661
Spinal Cord (Dorsal Column) Stimulator (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63662
Spinal Cord (Dorsal Column) Stimulator (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63663
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63664
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63685
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
63688
)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64400
Peripheral Nerve Blocks (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64405
Peripheral Nerve Blocks (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64415
Peripheral Nerve Blocks (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64416
Peripheral Nerve Blocks (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64417
Peripheral Nerve Blocks (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64418
Peripheral Nerve Blocks (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64420
Peripheral Nerve Blocks (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64421
Peripheral Nerve Blocks (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64425
Peripheral Nerve Blocks (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64430
)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64445
)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64446
)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64447
)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64448
)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64449
)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64450
Nerve blocks (CPT ), when performed at the same session as a surgical procedure, are
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64451
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64454
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64455
Therapeutic injections for neuroma ( , ) will be limited to three injections within six
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64479
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64480
Epidural Steroid Injections (ESI)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64483
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64484
Epidural Steroid Injections (ESI)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64490
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64491
Facet Joint Interventions ( , , , ) ( , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64492
Facet Joint Interventions ( , , , ) ( , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64493
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64494
Facet Joint Interventions ( , , , ) ( , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64495
Facet Joint Interventions ( , , , ) ( , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64550
9/1/2021 Removed termed code from Procedure Codes section
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64555
Required Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64566
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64567
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64568
Required Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64569
Not Required Not Required Not Required Not Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64570
Not Required Not Required Not Required Not Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64575
( , , , , , ) is considered experimental for any indication
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64580
L8689), when used in the treatment of spinal cord and head
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64582
• Surgical treatments
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64583
• Surgical treatments
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64584
• Surgical treatments
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64585
Not Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64590
effective date , , , , , , , ) as this is listed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64595
effective date , , , , , , , ) as this is listed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64624
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64625
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64628
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64629
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64632
Therapeutic injections for neuroma ( , ) will be limited to three injections within six
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64633
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64634
Facet Joint Interventions ( , , , ) ( , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64635
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64636
Facet Joint Interventions ( , , , ) ( , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64640
6/1/2023 Removed codes and in the therapeutic injections
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64654
Baroreflex stimulation implanted device (i.e., Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
64999
Exclusions and replaced with existing code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
65760
refractive errors (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
65765
refractive errors (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
65767
refractive errors (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
65770
refractive errors (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
65771
refractive errors (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
65772
refractive errors (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
65775
)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
65778
Placement of amniotic membrane on the ocular surface; without sutures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
65779
Single layer, sutured
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
65780
Ocular surface reconstruction; amniotic membrane transplantation, multiple
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
65781
Limbal stem cell allograft (e.g., cadaveric or living donor)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
65782
Limbal conjunctival autograft (includes obtaining graft)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
66170
Trabeculectomy (CPT® and ), an invasive procedure, is the current standard
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
66172
Trabeculectomy (CPT® and ), an invasive procedure, is the current standard
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
66183
Aqueous shunts/aqueous drainage devices (CPT®/HCPCS Codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
66658
Availability 10 mg/2 mL single-dose vial (NDC -501-01)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
66989
Aqueous shunts/aqueous drainage devices (CPT®/HCPCS Codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
66991
Aqueous shunts/aqueous drainage devices (CPT®/HCPCS Codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
66999
Viscocanalostomy Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67183
2025. Consistent with policies adopted in the CY 2016 and CY 2023 ESRD PPS final rules (see 80 FR and 87 FR )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67900
Brow ptosis repair
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67901
Blepharoptosis (upper eyelid ptosis)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67902
Blepharoptosis (upper eyelid ptosis)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67903
Blepharoptosis (upper eyelid ptosis)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67904
Blepharoptosis (upper eyelid ptosis)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67905
( ), upper eyelid blepharoplasty is not eligible for separate reimbursement
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67906
Blepharoptosis (upper eyelid ptosis)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67907
( ), upper eyelid blepharoplasty is not eligible for separate reimbursement
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67908
Blepharoptosis (upper eyelid ptosis)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67909
Blepharoptosis (upper eyelid ptosis)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67911
Eyelid (upper/lower) retraction
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67914
Eyelid (upper/lower) ectropion or entropion repair
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67915
Eyelid (upper/lower) ectropion or entropion repair
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67916
Eyelid (upper/lower) ectropion or entropion repair
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67917
Eyelid (upper/lower) ectropion or entropion repair
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67921
Eyelid (upper/lower) ectropion or entropion repair
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67922
Eyelid (upper/lower) ectropion or entropion repair
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67923
Eyelid (upper/lower) retraction: 67911
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67924
Eyelid (upper/lower) retraction: 67911
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
67999
Brow ptosis repair
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
68306
Available at: http://www.nice.org.uk/Docref.asp?d=
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
68841
Removed code as this is now in the Vision Services By
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69025
2025. Consistent with policies adopted in the CY 2016 and CY 2023 ESRD PPS final rules (see 80 FR and 87 FR )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69090
• Ear or body piercing ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69300
Required Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69705
Nasopharyngoscopy, surgical, with dilation of Eustachian tube (i.e., balloon
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69706
Nasopharyngoscopy, surgical, with dilation of Eustachian tube (i.e., balloon
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69710
Implantation or replacement of electromagnetic bone conduction hearing device in
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69711
Removal or repair of electromagnetic bone conduction hearing device in temporal
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69714
Implantation, osseointegrated implant, skull; with percutaneous attachment to
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69715
3/1/2022 • Removed deleted code (deleted code effective 1/1/2022)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69716
Implantation, osseointegrated implant, skull; with magnetic transcutaneous
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69717
Replacement (including removal of existing device), osseointegrated implant; skull
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69719
Replacement (including removal of existing device), osseointegrated implant, skull
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69726
Removal, entire osseointegrated implant, skull; with percutaneous attachment to
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69727
Removal, entire osseointegrated implant, skull; with magnetic transcutaneous
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69728
Removal, entire osseointegrated implant, skull; with magnetic transcutaneous
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69729
Implantation, osseointegrated implant, skull; with magnetic transcutaneous
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69730
Replacement (including removal of existing device), osseointegrated implant, skull
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69799
Unlisted procedure, middle ear
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
69930
Cochlear device implantation, with or without mastoidectomy
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70336
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70450
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70460
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70470
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70471
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70472
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70473
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70480
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70481
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70482
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70486
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70487
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70488
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70490
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70491
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70492
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70496
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70498
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70540
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70542
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70543
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70544
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70545
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70546
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70547
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70548
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70549
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70551
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70552
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70553
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70554
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
70555
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
71250
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
71260
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
71270
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
71271
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
71275
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
71550
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
71551
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
71552
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
71555
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72125
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72126
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72127
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72128
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72129
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72130
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72131
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72132
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72133
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72141
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72142
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72146
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72147
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72148
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72149
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72156
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72157
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72158
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72159
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72191
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72192
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72193
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72194
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72195
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72196
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72197
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72198
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
72275
Removed section on termed code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73200
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73201
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73202
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73206
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73218
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73219
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73220
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73221
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73222
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73223
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73225
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73600
Benefits will be provided for foot and ankle X-rays only (CPT codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73601
Benefits will be provided for foot and ankle X-rays only (CPT codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73602
Benefits will be provided for foot and ankle X-rays only (CPT codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73603
Benefits will be provided for foot and ankle X-rays only (CPT codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73604
Benefits will be provided for foot and ankle X-rays only (CPT codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73605
Benefits will be provided for foot and ankle X-rays only (CPT codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73606
Benefits will be provided for foot and ankle X-rays only (CPT codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73607
Benefits will be provided for foot and ankle X-rays only (CPT codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73608
Benefits will be provided for foot and ankle X-rays only (CPT codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73609
Benefits will be provided for foot and ankle X-rays only (CPT codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73610
Benefits will be provided for foot and ankle X-rays only (CPT codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73620
Benefits will be provided for foot and ankle X-rays only (CPT codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73660
), and are subject to the following
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73700
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73701
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73702
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73706
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73718
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73719
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73720
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73721
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73722
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73723
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
73725
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
74150
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
74160
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
74170
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
74174
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
74175
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
74176
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
74177
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
74178
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
74181
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
74182
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
74183
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
74185
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
74261
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
74262
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
74263
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
74445
• Cavernosometry or cavernosography ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
74712
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
75557
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
75559
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
75561
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
75563
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
75571
• CT Heart, including quantitative evaluation of coronary calcium
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
75572
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
75573
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
75577
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
75580
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
75635
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
76120
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
76125
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
76376
CT, MRI, ultrasound, or other tomographic modality
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
76377
CT, MRI, ultrasound, or other tomographic modality
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
76380
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
76390
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
76391
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
76497
• Virtual Bronchoscopy
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
76498
• MRI 3 tesla (3T)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
76882
Ultrasound of the foot ( ) is considered to be an integral part of the ultrasonic guidance for
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
76942
needle placement ( ) and therefore is not separately reimbursed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77003
Fluoroscopic guidance ( ) is considered an integral part of the injection procedure
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77046
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77047
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77048
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77049
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77084
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77085
Vertebral fracture assessment (VFA) Screening for vertebral fractures using
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77086
dual X-ray absorptiometry (DXA) as a
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77371
Stereotactic radiosurgery
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77372
Stereotactic radiosurgery
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77373
Stereotactic body radiosurgery
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77432
Stereotactic body radiosurgery: 77373, 77435
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77435
Stereotactic body radiosurgery
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77436
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77437
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77438
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77439
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77520
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77522
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77523
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
77525
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78429
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78430
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78431
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78432
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78433
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78451
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78452
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78453
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78454
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78459
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78466
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78468
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78469
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78472
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78473
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78481
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78483
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78491
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78492
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78494
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78608
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78609
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78811
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78812
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78813
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78814
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78815
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78816
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
78999
Positron emission tomography (FDG) for Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
80305
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
80306
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
80307
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81105
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81106
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81107
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81108
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81109
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81110
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81111
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81112
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81120
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81121
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81161
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81162
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81163
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81164
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81165
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81166
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81167
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81168
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81170
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81171
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81172
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81173
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81174
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81175
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81176
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81177
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81178
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81179
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81180
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81181
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81182
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81183
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81184
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81185
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81186
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81187
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81188
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81189
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81190
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81191
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81192
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81193
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81194
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81195
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81200
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81201
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81202
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81203
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81204
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81205
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81206
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81207
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81208
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81209
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81210
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81212
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81215
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81216
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81217
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81218
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81219
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81221
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81222
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81223
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81224
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81225
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81226
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81227
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81228
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81229
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81230
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81231
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81232
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81233
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81234
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81235
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81236
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81237
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81238
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81239
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81240
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81241
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81242
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81243
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81244
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81245
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81246
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81247
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81248
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81249
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81250
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81251
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81252
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81253
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81254
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81255
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81256
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81257
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81258
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81259
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81260
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81261
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81262
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81263
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81264
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81265
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81266
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81267
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81268
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81269
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81270
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81271
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81272
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81273
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81274
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81275
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81276
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81277
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81278
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81279
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81283
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81284
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81285
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81286
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81287
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81288
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81289
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81290
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81291
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81292
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81293
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81294
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81295
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81296
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81297
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81298
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81299
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81300
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81301
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81302
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81303
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81304
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81305
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81306
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81307
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81308
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81309
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81310
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81311
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81312
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81313
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81314
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81315
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81316
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81317
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81318
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81319
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81320
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81321
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81322
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81323
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81324
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81325
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81326
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81327
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81328
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81330
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81331
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81332
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81333
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81334
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81335
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81336
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81337
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81338
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81339
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81340
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81341
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81342
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81343
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81344
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81345
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81346
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81347
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81348
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81349
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81350
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81351
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81352
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81353
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81354
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81355
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81357
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81360
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81361
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81362
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81363
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81364
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81370
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81371
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81372
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81373
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81374
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81375
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81376
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81377
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81378
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81379
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81380
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81381
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81382
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81383
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81400
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81401
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81402
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81403
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81404
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81405
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81406
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81407
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81408
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81410
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81411
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81412
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81413
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81414
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81415
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81416
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81417
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81418
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81419
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81422
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81425
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81426
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81427
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81430
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81431
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81432
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81434
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81435
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81436
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81437
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81439
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81440
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81441
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81442
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81443
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81445
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81448
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81449
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81450
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81451
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81455
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81456
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81457
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81458
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81459
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81460
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81462
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81463
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81464
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81465
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81470
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81471
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81479
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81490
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81493
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81504
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81507
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81518
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81519
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81520
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81521
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81522
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81523
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81524
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81525
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81529
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81540
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81541
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81542
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81546
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81551
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81552
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81554
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81558
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81595
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
81599
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
82785
Gammaglobulin (immunoglobulin), IgE
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
83987
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
84999
Avise PG to measure methotrexate Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
86001
(E/I) Allergen-specific IgG; quantitative or semiquantitative, each allergen
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
86003
Allergen-specific IgE; quantitative or semiquantitative, crude allergen extract, each
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
86005
Allergen-specific IgE; qualitative, multi-allergen screen (e.g., disk, sponge, card)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
86008
Allergen-specific IgE; quantitative or semiquantitative, recombinant or purified
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
86152
Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
86153
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
86343
(E/I) Leukocyte histamine release test (LHR)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
86701
( ), when part of a family planning visit from any
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
86849
Antiprothrombin (phospholipid cofactor) Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
88104
Oral brush biopsy (e.g., Oral CDx) for The sensitivity and specificity of the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
88141
Pap Smears for members under 21 years of , Considered not medically necessary
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
88142
Pap Smears for members under 21 years of , Considered not medically necessary
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
88143
age , except in the following circumstances
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
88147
age , except in the following circumstances
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
88148
88152,88153, • HIV-infected women beginning in
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
88150
88152,88153, • HIV-infected women beginning in
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
88152
• HIV-infected women beginning in
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
88153
• HIV-infected women beginning in
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
88154
adolescence
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
88164
• Sexually active immunocompromised
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
88165
• Sexually active immunocompromised
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
88166
adolescent women, including those
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
88167
adolescent women, including those
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
88174
who have received an organ
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
88175
who have received an organ
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
88299
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
88749
Skin advanced glycogen end products Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89250
Invitro-fertilization
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89253
Required Not Required Not Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89254
Invitro-fertilization
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89255
Invitro-fertilization
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89258
invitro-fertilization (IVF) services
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89259
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89260
• Sperm washing ( ), sperm isolation ( , ), sperm count
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89261
• Sperm washing ( ), sperm isolation ( , ), sperm count
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89268
Invitro-fertilization
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89272
Invitro-fertilization
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89280
Invitro-fertilization
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89281
Invitro-fertilization
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89310
( , ), and repeat semen analysis ( ) may be separately reimbursed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89320
( , ), and repeat semen analysis ( ) may be separately reimbursed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89335
Cryopreservation
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89337
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89342
invitro-fertilization (IVF) services
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89343
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89344
Storage
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89346
of oocytes/embryos from a fresh retrieval ( - embryo(s) storage per year, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89352
invitro-fertilization (IVF) services
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89353
Invitro-fertilization
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89354
Thawing
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89356
Invitro-fertilization
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
89398
Cryopreservation
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
90503
3. Endari prescribing information, Emmaus Medical Inc. Torrance, CA 10/20 11/24
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
90791
Other Licensed Practitioner (OLP)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
90832
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
90867
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
90868
Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
90869
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
90870
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
90875
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
90876
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
90882
Other Licensed Practitioner (OLP)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
90901
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
90911
1/1/2020 Removed deleted code and replaced with new codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
90912
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
90913
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92002
Ophthalmological visits
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92012
Ophthalmological visits
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92065
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92066
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92071
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92072
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92130
2 Filspari (sparsentan) prescribing information. Travere Therapeutics, Inc., San Diego, CA 8/2025 2/2026
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92145
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92227
Remote Imaging Fundus Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92228
Photography/Retinal telescreening (i.e., unproven
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92229
RetinaVue™, Optomap®) Exception: Coverage for retinal
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92310
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92313
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92314
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92340
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92341
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92342
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92343
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92344
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92345
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92346
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92347
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92348
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92349
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92350
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92351
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92352
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92353
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92354
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92355
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92356
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92357
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92358
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92359
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92360
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92361
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92362
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92363
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92364
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92365
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92366
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92367
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92368
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92369
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92370
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92371
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92499
(i.e., PROSE) ( , , , , , , ) are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92507
Required Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92508
Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92511
Nasopharyngoscopy with endoscope (separate procedure)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92521
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92522
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92523
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92524
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92526
Required Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92548
Computerized dynamic posturography Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92601
Diagnostic analysis of cochlear implant, patient younger than 7 years of age; with
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92602
subsequent reprogramming
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92603
Diagnostic analysis of cochlear implant, age 7 years or older; with programming
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92604
subsequent reprogramming
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92605
Evaluation for prescription of non-speech-generating augmentative and alternative
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92618
each additional 30 minutes (List separately in addition to code for primary
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92622
Diagnostic analysis, programming, and verification of an auditory osseointegrated
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92623
each additional 15 minutes (List separately in addition to code for primary
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92640
Diagnostic analysis with programming of auditory brain stem implant, per hour
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
92972
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93000
CDPHP does not allow separate reimbursement for CPT (routine
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93001
CDPHP does not allow separate reimbursement for CPT (routine
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93002
CDPHP does not allow separate reimbursement for CPT (routine
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93003
CDPHP does not allow separate reimbursement for CPT (routine
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93004
CDPHP does not allow separate reimbursement for CPT (routine
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93005
CDPHP does not allow separate reimbursement for CPT (routine
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93006
CDPHP does not allow separate reimbursement for CPT (routine
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93007
CDPHP does not allow separate reimbursement for CPT (routine
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93008
CDPHP does not allow separate reimbursement for CPT (routine
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93009
CDPHP does not allow separate reimbursement for CPT (routine
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93010
CDPHP does not allow separate reimbursement for CPT (routine
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93040
electrocardiogram) and (rhythm electrocardiogram) when billed with
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93041
electrocardiogram) and (rhythm electrocardiogram) when billed with
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93042
electrocardiogram) and (rhythm electrocardiogram) when billed with
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93050
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93228
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93229
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93264
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93451
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93452
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93453
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93454
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93455
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93456
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93457
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93458
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93459
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93460
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93461
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93593
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93594
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93595
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93596
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93597
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93600
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93602
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93603
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93610
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93612
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93615
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93616
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93618
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93619
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93620
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93624
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93631
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93640
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93641
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93642
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93644
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93650
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93653
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93654
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93656
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93668
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93702
Not Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93740
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93745
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93797
Cardiac Rehabilitation
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93798
Cardiac Rehabilitation
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
93998
Common carotid intima-media thickness Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
94080
9 RITUXAN (rituximab) prescribing information, Genentech, Inc., South San Francisco, CA . 12/21 11/24
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
94625
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
94626
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
94726
Air displacement/body plethymography for Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
94750
code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95004
Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95017
Allergy testing, any combination of percutaneous (scratch, puncture, prick) and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95018
Allergy testing, any combination of percutaneous (scratch, puncture, prick) and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95024
Intracutaneous (intradermal) tests with allergenic extracts, immediate type
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95027
Intracutaneous (intradermal) tests, sequential and incremental, with allergenic
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95028
Intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95044
Patch or application test(s) (specify number of tests)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95052
Photo patch test(s) (specify number of tests)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95056
Photo tests
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95060
(E/I) Ophthalmic mucous membrane tests
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95065
(E/I) Direct nasal mucous membrane test
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95070
Inhalation bronchial challenge testing (not including necessary pulmonary function
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95071
11/1/2021 • Removed termed code from Procedure Codes section
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95075
11/1/20 • Removed termed code from Procedure Codes section
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95076
Ingestion challenge test (sequential and incremental ingestion of test items, e.g
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95079
Ingestion challenge test (sequential and incremental ingestion of test items, e.g
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95165
9/1/2025 • Removed statement from Policy Considerations regarding as it is
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95249
Professional glucose monitoring ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95250
Professional glucose monitoring ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95251
Professional glucose monitoring ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95700
Ambulatory Electroencephalography (EEG)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95705
Ambulatory Electroencephalography (EEG)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95706
Ambulatory Electroencephalography (EEG)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95707
Ambulatory Electroencephalography (EEG)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95708
Ambulatory Electroencephalography (EEG)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95709
Ambulatory Electroencephalography (EEG)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95710
95722, 95723, 95724, 95725, 95726
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95711
95722, 95723, 95724, 95725, 95726
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95712
95722, 95723, 95724, 95725, 95726
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95713
95722, 95723, 95724, 95725, 95726
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95714
95722, 95723, 95724, 95725, 95726
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95715
95722, 95723, 95724, 95725, 95726
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95716
95722, 95723, 95724, 95725, 95726
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95717
95722, 95723, 95724, 95725, 95726
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95718
95722, 95723, 95724, 95725, 95726
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95719
95722, 95723, 95724, 95725, 95726
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95720
95722, 95723, 95724, 95725, 95726
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95721
95722, 95723, 95724, 95725, 95726
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95722
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95723
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95724
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95725
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95726
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95782
Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95783
Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95800
• Unattended (home-based) sleep testing
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95801
• Unattended (home-based) sleep testing
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95803
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95805
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95806
• Unattended (home-based) sleep testing
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95807
Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95808
Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95810
Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95811
Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95812
Routine “Resting” Electroencephalography (EEG)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95813
Routine “Resting” Electroencephalography (EEG)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95816
Routine “Resting” Electroencephalography (EEG)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95819
Routine “Resting” Electroencephalography (EEG)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95822
Routine “Resting” Electroencephalography (EEG)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95925
• Somatosensory evoked potential studies ( , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95926
• Somatosensory evoked potential studies ( , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95970
0912T
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95976
0912T
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95977
0912T
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95980
effective date , , , , , , , ) as this is listed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95981
effective date , , , , , , , ) as this is listed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95982
effective date , , , , , , , ) as this is listed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95990
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
95991
Implantable infusion pumps ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96000
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96001
5/1/2020 Removed gait analysis ( ) from the Exclusions
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96002
5/1/2020 Removed gait analysis ( ) from the Exclusions
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96003
5/1/2020 Removed gait analysis ( ) from the Exclusions
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96004
5/1/2020 Removed gait analysis ( ) from the Exclusions
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96116
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96121
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96130
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96131
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96132
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96133
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96136
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96137
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96138
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96139
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96146
Required Not Required Required Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96152
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96156
8/1/2023 Added and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96159
8/1/2023 Added and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96365
Intravenous infusion (CPT)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96366
Intravenous infusion (CPT)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96367
Intravenous infusion (CPT)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96368
Intravenous infusion (CPT)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96372
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96904
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96920
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96921
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
96922
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97005
*No change to policy codes and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97006
*No change to policy codes and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97010
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97011
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97012
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97013
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97014
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97015
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97016
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97017
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97018
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97019
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97020
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97021
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97022
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97023
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97024
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97025
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97026
Infrared therapy used for the treatment of Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97027
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97028
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97029
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97030
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97031
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97032
Benefits are provided for electrical stimulation ( ) when used as a means of therapeutic
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97033
Iontophoresis for primary focal hyperhidrosis Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97034
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97035
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97036
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97037
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97038
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97039
professional (i.e., MD, physical therapist)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97110
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97111
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97112
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97113
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97114
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97115
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97116
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97117
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97118
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97119
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97120
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97121
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97122
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97123
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97124
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97125
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97126
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97127
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97128
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97129
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97130
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97131
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97132
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97133
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97134
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97135
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97136
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97137
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97138
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97139
Microvas vascular treatment system for Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97140
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97141
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97142
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97143
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97144
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97145
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97146
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97147
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97148
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97149
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97150
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97151
PROCEDURE CODES
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[PDF] CDPHP Policies List - AWS
97152
PROCEDURE CODES
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PROCEDURE CODES
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PROCEDURE CODES
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PROCEDURE CODES
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PROCEDURE CODES
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PROCEDURE CODES
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97158
PROCEDURE CODES
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[PDF] CDPHP Policies List - AWS
97159
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97160
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97161
of service as physical medicine and rehabilitation evaluation codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97162
of service as physical medicine and rehabilitation evaluation codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97163
of service as physical medicine and rehabilitation evaluation codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97164
of service as physical medicine and rehabilitation evaluation codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97165
of service as physical medicine and rehabilitation evaluation codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97166
Evaluation
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97167
Evaluation
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97168
)
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)
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)
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)
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97172
)
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[PDF] CDPHP Policies List - AWS
97173
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97174
Therapeutic Procedures
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97175
Therapeutic Procedures
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97176
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97177
Therapeutic Procedures
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97178
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97179
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97180
Therapeutic Procedures
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97181
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97182
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97183
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97184
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97185
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97186
Therapeutic Procedures
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97187
Therapeutic Procedures
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97188
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97189
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97190
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97191
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97192
Therapeutic Procedures
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97193
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97194
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97195
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97196
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97197
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97198
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97199
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97200
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97201
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97202
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97203
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97204
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97205
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97206
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97207
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97208
Therapeutic Procedures
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97209
Therapeutic Procedures
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97210
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Therapeutic Procedures
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Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97213
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97214
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
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Therapeutic Procedures
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Therapeutic Procedures
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Therapeutic Procedures
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Therapeutic Procedures
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Therapeutic Procedures
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97220
Therapeutic Procedures
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Therapeutic Procedures
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Therapeutic Procedures
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97223
Therapeutic Procedures
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Therapeutic Procedures
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Therapeutic Procedures
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Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97228
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97229
Therapeutic Procedures
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97230
Therapeutic Procedures
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Therapeutic Procedures
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97232
Therapeutic Procedures
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Therapeutic Procedures
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Therapeutic Procedures
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Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97236
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97237
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97238
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
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Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97240
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97241
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97242
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97243
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
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Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
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Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
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Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97247
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97248
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97249
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97250
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97251
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97252
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97253
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97254
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97255
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97256
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97257
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97258
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97259
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97260
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97261
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97262
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97263
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97264
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97265
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97266
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97267
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97268
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97269
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97270
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97271
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97272
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97273
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97274
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97275
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97276
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97277
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97278
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97279
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97280
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97281
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97282
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97283
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97284
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97285
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97286
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97287
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97288
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97289
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97290
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97291
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97292
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97293
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97294
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97295
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97296
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97297
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97298
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97299
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97300
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97301
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97302
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97303
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97304
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97305
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97306
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97307
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97308
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97309
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97310
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97311
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97312
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97313
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97314
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97315
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97316
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97317
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97318
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97319
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97320
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97321
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97322
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97323
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97324
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97325
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97326
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97327
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97328
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97329
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97330
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97331
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97332
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97333
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97334
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97335
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97336
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97337
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97338
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97339
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97340
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97341
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97342
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97343
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97344
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97345
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97346
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97347
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97348
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97349
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97350
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97351
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97352
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97353
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97354
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97355
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97356
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97357
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97358
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97359
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97360
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97361
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97362
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97363
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97364
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97365
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97366
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97367
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[PDF] CDPHP Policies List - AWS
97368
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[PDF] CDPHP Policies List - AWS
97369
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97370
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97371
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97372
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97373
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97374
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97375
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97376
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97377
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97378
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97379
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97380
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[PDF] CDPHP Policies List - AWS
97381
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97382
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97383
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97384
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97385
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97386
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97387
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97388
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97389
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97390
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97391
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97392
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97393
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97394
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97395
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97396
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97397
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97398
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97399
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97400
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97401
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97402
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97403
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97404
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97405
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97406
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97407
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97408
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97409
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97410
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97411
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97412
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97413
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97414
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97415
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97416
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97417
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97418
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97419
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97420
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97421
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97422
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97423
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97424
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97425
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97426
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97427
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97428
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97429
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97430
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97431
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97432
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97433
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97434
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97435
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97436
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97437
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97438
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97439
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97440
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97441
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97442
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97443
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97444
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97445
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97446
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97447
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97448
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97449
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97450
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97451
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97452
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97453
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97454
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97455
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97456
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97457
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97458
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97459
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97460
Therapeutic Procedures
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[PDF] CDPHP Policies List - AWS
97461
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97462
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97463
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97464
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97465
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97466
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97467
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97468
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97469
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97470
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97471
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97472
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97473
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97474
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97475
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97476
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97477
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97478
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97479
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97480
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97481
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97482
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97483
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97484
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97485
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97486
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97487
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97488
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97489
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97490
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97491
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97492
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97493
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97494
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97495
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97496
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97497
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97498
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97499
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97500
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97501
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97502
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97503
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97504
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97505
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97506
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97507
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97508
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97509
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97510
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97511
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97512
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97513
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97514
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97515
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97516
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97517
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97518
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97519
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97520
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97521
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97522
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97523
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97524
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97525
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97526
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97527
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97528
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97529
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97530
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97531
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97532
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97533
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97534
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97535
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97536
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97537
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97538
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97539
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97540
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97541
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97542
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97543
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97544
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97545
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97546
Therapeutic Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97607
Required Required Required Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97608
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97610
Not Required Required Not Required Not Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97750
Tests & Measurements
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97751
( , are non
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97752
( , are non
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97753
( , are non
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97754
( , are non
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97755
Tests & Measurements
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97760
Orthotic & Prosthetic Management
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97761
Orthotic & Prosthetic Management
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97762
Orthotic & Prosthetic Management
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
97763
Orthotic & Prosthetic Management
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
98940
)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
98941
)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
98942
)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
98943
Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
98975
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
98976
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
98977
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
98978
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
98979
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
98980
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
98981
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
98984
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
98985
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
98986
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99091
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99183
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99188
( , , ) for children from birth through age five when applied by a dentist
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99199
measurement of body composition (BOD- unproven
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99202
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99203
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99204
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99205
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99206
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99207
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99208
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99209
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99210
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99211
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99212
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99213
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99214
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99215
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99216
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99217
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99218
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99219
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99220
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99221
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99222
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99223
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99224
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99225
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99226
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99227
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99228
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99229
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99230
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99231
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99232
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99233
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99234
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99235
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99236
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99237
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99238
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99239
CDPHP will not separately reimburse for evaluation and management codes (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99281
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99282
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99283
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99284
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99285
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99286
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99287
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99288
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99289
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99290
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99291
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99292
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99293
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99294
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99295
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99296
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99297
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99298
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99299
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99300
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99301
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99302
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99303
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99304
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99305
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99306
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99307
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99308
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99309
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99310
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99311
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99312
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99313
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99314
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99315
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99316
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99317
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99318
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99319
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99320
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99321
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99322
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99323
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99324
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99325
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99326
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99327
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99328
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99329
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99330
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99331
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99332
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99333
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99334
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99335
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99336
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99337
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99338
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99339
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99340
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99341
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99342
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99343
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99344
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99345
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99346
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99347
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99348
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99349
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99350
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99351
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99352
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99353
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99354
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99355
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99356
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99357
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99358
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99359
) in conjunction with diabetes education ( , , ) when billed by
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99445
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99453
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99454
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99457
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99458
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99470
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99500
prenatal or postnatal home health care nurse ( , ) visit when the woman may derive
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99501
prenatal or postnatal home health care nurse ( , ) visit when the woman may derive
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99502
• Other Home Health Services/Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99503
• Other Home Health Services/Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99504
• Other Home Health Services/Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99505
• Other Home Health Services/Procedures
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99506
• Physical Therapist: S9131, G0151
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99507
• Physical Therapist: S9131, G0151
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99509
Custodial care ( ) or rest cures and services rendered for the convenience of an enrollee
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99511
• Physical Therapist: S9131, G0151
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99512
• Physical Therapist: S9131, G0151
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99600
• Physical Therapist: S9131, G0151
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99601
• Home Infusion services
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
99602
• Home Infusion services
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0021
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0080
wheelchair van and/or private or commercial air transportation ( – , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0090
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0100
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0110
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0120
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0130
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0140
wheelchair van and/or private or commercial air transportation ( – , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0160
fees, tolls, lodging, or meals for either the escort or recipient ( - )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0210
fees, tolls, lodging, or meals for either the escort or recipient ( - )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0382
Reimbursement for routine disposable supplies ( - , - , ) is
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0384
Reimbursement for routine disposable supplies ( - , - , ) is
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0392
Reimbursement for routine disposable supplies ( - , - , ) is
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0398
Reimbursement for routine disposable supplies ( - , - , ) is
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0420
Ambulance waiting time ( ) is not eligible for coverage
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0422
Reimbursement for routine disposable supplies ( - , - , ) is
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0424
No additional benefits are available for extra ambulance attendants ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0425
Reimbursement for ground mileage ( ) will be provided in addition to the basic emergency
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0426
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0428
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0430
Air ambulance ( , , , ) transport is considered medically necessary
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0431
Air ambulance ( , , , ) transport is considered medically necessary
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0432
Paramedic intercept services ( ) are ALS services delivered by paramedics that operate
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0434
Specialty care transport ( ) is the inter-facility transportation of a critically injured or ill
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0435
Air ambulance ( , , , ) transport is considered medically necessary
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0436
Air ambulance ( , , , ) transport is considered medically necessary
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A0998
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2001
(E/I) Innovamatrix ac, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2002
(E/I) Mirragen advanced wound matrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2004
(E/I) Xcellistem, 1 mg
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2005
(E/I) Microlyte matrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2007
(E/I) Restrata, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2008
(E/I) TheraGenesis, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2009
(E/I) Symphony, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2010
(E/I) Apis, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2011
(E/I) Supra SDRM, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2012
(E/I) SUPRATHEL, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2013
(E/I) Innovamatrix FS, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2014
(E/I) Omeza collagen matrix, per 100 mg
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2015
(E/I) Phoenix wound matrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2016
(E/I) PermeaDerm B, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2017
(E/I) PermeaDerm glove, each
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2018
(E/I) PermeaDerm C, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2019
(E/I) Kerecis Omega3 MariGen shield, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2020
(E/I) AC5 Advanced Wound System (AC5)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2021
(E/I) NeoMatrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2022
10/1/2023 • Added new codes - , and - to Exclusions section
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2025
10/1/2023 • Added new codes - , and - to Exclusions section
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2026
(E/I) Restrata MiniMatrix, 5 mg
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2027
(E/I) MatriDerm, per sq cm (effective 10/01/24)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2028
(E/I) MicroMatrix Flex, per mg (effective 10/01/24)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2029
(E/I) MiroTract Wound Matrix sheet, per cc (effective 10/01/24)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2030
(E/I) Miro3d fibers, per milligram (effective 04/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2031
(E/I) Mirodry wound matrix, per square centimeter (effective 04/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2032
(E/I) Myriad matrix, per square centimeter (effective 04/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2033
(E/I) Myriad morcells, 4 milligrams (effective 04/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2034
(E/I) Foundation drs solo, per square centimeter (effective 04/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2035
(E/I) Corplex p or theracor p or allacor p, per milligram
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2036
(E/I) Cohealyx Collagen Dermal Matrix, per sq cm (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2037
(E/I) G4Derm Plus, per ml (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2038
(E/I) MariGen Pacto, per sq cm (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A2039
(E/I) InnovaMatrix FD, per sq cm (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4100
Skin substitute, FDA-cleared as a device, not otherwise specified
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4238
( , , , , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4239
( , , , , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4305
1/1/2022 Removed / (Drug delivery system) from grid as they
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4306
1/1/2022 Removed / (Drug delivery system) from grid as they
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4457
1/1/2024 Replaced termed code with new code in Select
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4468
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4490
Codes , , , are non-covered
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4495
Codes , , , are non-covered
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4500
Codes , , , are non-covered
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4510
Codes , , , are non-covered
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4540
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4542
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4543
Transcutaneous Electrical Nerve Stimulator, , Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4545
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4556
Codes (Electrodes, [e.g., apnea monitor], per pair), (conductive paste or gel), and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4558
Codes (Electrodes, [e.g., apnea monitor], per pair), (conductive paste or gel), and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4575
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4595
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4596
(i.e., Fisher Wallace Stimulator) including unproven
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4606
Pulse oximeter probes ( ) are used with the oximeter ( ) and are included in the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4630
(replacement batteries) should not be billed separately, and no separate allowance will be
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4639
Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A4670
Automatic Blood Pressure Cuff ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A5500
Therapeutic Shoes for Diabetics
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A5501
Therapeutic Shoes for Diabetics
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A5503
Therapeutic Shoes for Diabetics
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A5504
bottoms ( ), wedges ( ), metatarsal bars ( ), or offset heels ( ). Other
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A5505
bottoms ( ), wedges ( ), metatarsal bars ( ), or offset heels ( ). Other
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A5506
bottoms ( ), wedges ( ), metatarsal bars ( ), or offset heels ( ). Other
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A5507
Therapeutic Shoes for Diabetics
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A5508
A deluxe feature of a diabetic shoe ( ) does not contribute to the therapeutic function of
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A5510
Compression molding inserts ( ) are considered non-covered, as they do not require total
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A5512
Therapeutic Shoe Inserts
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A5513
Therapeutic Shoe Inserts
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A5514
Therapeutic Shoe Inserts
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6448
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6450
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6451
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6452
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6515
A6593, A6610, A6611, S8420-S8428.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6519
A6593, A6610, A6611, S8420-S8428.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6520
A6593, A6610, A6611, S8420-S8428.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6529
A6593, A6610, A6611, S8420-S8428.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6530
A6593, A6610, A6611, S8420-S8428.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6533
A6593, A6610, A6611, S8420-S8428.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6538
A6593, A6610, A6611, S8420-S8428.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6540
A6593, A6610, A6611, S8420-S8428.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6544
A6593, A6610, A6611, S8420-S8428.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6545
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6549
A6593, A6610, A6611, S8420-S8428.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6552
A6593, A6610, A6611, S8420-S8428.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6589
A6593, A6610, A6611, S8420-S8428.
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6593
The following codes will be allowed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6594
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6609
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6610
The following codes will be allowed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A6611
The following codes will be allowed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A7021
Lung expansion airway clearance, , Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A7048
Vacuum drainage collection unit and tubing kit ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A7049
)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A9272
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A9274
➢ Omnipod Insulin Management System
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A9276
( , , , , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A9277
( , , , , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A9278
( , , , , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A9282
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A9586
Removed from experimental services (please see
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A9587
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A9593
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A9594
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A9595
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A9596
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A9597
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A9608
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A9800
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A9900
Iontophoresis device for home use for , , Experimental, investigational or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
A9999
hyperhidrosis (i.e., Dermadry, miraDry) unproven
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
B9002
• Enteral nutrition infusion pump ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C1605
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C1721
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C1722
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C1761
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C1764
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C1777
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C1779
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C1785
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C1786
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C1821
Not Required Not Required Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C1878
lines, corners of the mouth, and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C1882
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C1895
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C1896
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C1898
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C1899
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C1900
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C2596
Probe, image guided, robotic, waterjet ablation
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C2614
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C2619
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C2620
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C2621
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C2624
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C2625
Stent, non-coronary, temporary, with delivery system (Propel™)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C5271
Application of low-cost skin substitute graft to trunk, arms, legs, total wound
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C5272
Application of low-cost skin substitute graft to trunk, arms, legs, total wound
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C5273
Application of low-cost skin substitute graft to trunk, arms, legs, total wound
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C5274
each additional 100 sq cm wound surface area, or part thereof, or each additional
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C5275
Application of low-cost skin substitute graft to face, scalp, eyelids, mouth, neck
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C5276
each additional 25 sq cm or less wound surface area, or part thereof
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C5277
Application of low-cost skin substitute graft to face, scalp, eyelids, mouth, neck
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C5278
each additional 100 sq cm wound surface area, or part thereof, or each additional
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C7509
Electromagnetic navigation bronchoscopy , , Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C7510
(ENB) for peripheral lung lesions (e.g., , unproven
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C7511
virtual bronchoscopy) , Exception: Covered for Medicare
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C7567
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8900
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8901
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8902
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8903
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8905
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8906
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8908
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8909
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8910
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8911
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8912
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8913
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8914
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8918
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8919
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8920
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8931
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8932
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8933
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8934
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8935
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8936
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C8937
• Computer-aided detection (CAD), breast MRI
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9047
HCPCS
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9122
Removed termed code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9354
(E/I) Acellular pericardial tissue matrix of non-human origin (Veritas), per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9356
(E/I) Tendon, porous matrix of cross-linked collagen and glycosaminoglycan matrix
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9358
Dermal substitute, native, nondenatured collagen, fetal bovine origin (SurgiMend
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9360
Dermal substitute, native, nondenatured collagen, neonatal bovine origin
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9363
(E/I) Skin substitute (Integra Meshed Bilayer Wound Matrix), per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9364
(E/I) Porcine implant, Permacol, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9727
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9734
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9739
Cystourethroscopy, with insertion of transprostatic implant; one to three implants
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9740
Cystourethroscopy, with insertion of transprostatic implant; four or more implants
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9741
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9757
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9762
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9763
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9764
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9765
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9766
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9767
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9771
Cryoablation of the posterior nasal nerve Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9772
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9773
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9774
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9775
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9784
(E/I) Gastric restrictive procedure, endoscopic sleeve gastroplasty, with
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9785
(E/I) Endoscopic outlet reduction, gastric pouch application, with endoscopy and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9795
Stereotactic body radiosurgery: 77373, 77435
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9808
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9809
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
C9817
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
D1206
( , , ) for children from birth through age five when applied by a dentist
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
D1208
( , , ) for children from birth through age five when applied by a dentist
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
D5924
Billing of code (cranial prosthesis) is not an appropriate code for purposes of this policy
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
D7288
screening of mouth cancer office- based test compromise ability to
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
D9947
• Oral Appliances
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
D9948
• Oral Appliances
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
D9949
• Oral Appliances
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0100
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0105
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0110
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0111
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0112
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0113
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0114
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0116
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0117
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0118
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0130
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0135
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0140
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0141
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0143
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0144
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0147
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0148
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0149
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0152
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0153
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0154
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0155
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0156
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0157
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0158
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0159
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0160
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0161
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0162
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0163
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0165
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0167
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0168
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0170
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0171
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0172
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0175
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0181
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0182
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0183
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0184
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0185
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0186
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0187
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0188
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0189
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0193
Not Required Not Required Y if rental or over 1K Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0194
Y if rental or over 1K Y if rental or over 1K Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0196
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0197
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0198
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0199
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0200
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0201
• Penile contracture device, manual, greater than 3 lbs. traction force ( ) is considered
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0202
Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0203
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0205
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0210
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0215
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0217
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0218
Electrical water-circulating cold pad with Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0221
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0225
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0231
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0235
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0236
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0239
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0240
Y if rental or over 1K Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0241
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0242
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0243
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0244
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0245
Y if rental or over 1K Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0246
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0247
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0248
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0249
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0250
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0251
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0255
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0256
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0260
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0261
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0265
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0266
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0270
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0271
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0272
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0273
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0274
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0275
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0276
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0277
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0280
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0290
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0291
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0292
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0293
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0294
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0295
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0296
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0297
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0300
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0301
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0302
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0303
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0304
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0305
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0310
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0315
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0316
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0325
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0326
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0328
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0329
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0350
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0352
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0370
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Not Required Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0371
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0372
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0373
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0445
Not Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0446
Y if rental or over 1K Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0450
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0457
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0459
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0460
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0461
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0462
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0463
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0464
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0465
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0466
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0467
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0468
Y if rental or over 1K Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0469
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0470
• CPAP/BiPAP/APAP equipment
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0471
• CPAP/BiPAP/APAP equipment
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0472
• CPAP/BiPAP/APAP equipment
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0480
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0481
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0482
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0483
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0484
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0485
Required Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0486
Y if rental or over 1K Y if rental or over 1K Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0490
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0491
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0492
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0493
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0500
Not Required Not Required Y if rental or over 1K Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0530
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0561
• CPAP/BiPAP/APAP equipment
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0562
• CPAP/BiPAP/APAP equipment
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0565
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0570
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0572
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0574
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0575
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0585
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0600
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0601
• CPAP/BiPAP/APAP equipment
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0602
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0603
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0604
Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0605
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0606
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0607
Required Not Required Not Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0610
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0615
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0616
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0617
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0618
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0619
Not Required Not Required Y if rental or over 1K Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0621
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0625
Not Required Not Required Y if rental or over 1K Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0627
Not Required Y if rental or over 1K Y if rental or over 1K Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0628
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0629
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0630
Not Required Not Required Y if rental or over 1K Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0635
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0636
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0637
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0638
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0639
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0640
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0641
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0642
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0650
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0651
Y if rental or over 1K Y if rental or over 1K Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0652
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0655
Not Required Not Required Y if rental or over 1K Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0656
Not Required Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0657
Required Not Required Not Required Not Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0658
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0659
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0660
Y if rental or over 1K Not Required Y if rental or over 1K Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0665
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0666
Not Required Not Required Y if rental or over 1K Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0667
Y if rental or over 1K Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0668
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0669
Not Required Not Required Y if rental or over 1K Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0670
Not Required Not Required Y if rental or over 1K Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0671
Y if rental or over 1K Y if rental or over 1K Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0672
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0673
Y if rental or over 1K Not Required Not Required Not Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0675
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0676
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0677
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0678
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0679
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0680
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0681
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0682
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0683
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0691
Not Required Y if rental or over 1K Y if rental or over 1K Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0692
Not Required Y if rental or over 1K Y if rental or over 1K Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0693
Not Required Y if rental or over 1K Y if rental or over 1K Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0694
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0700
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0705
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0710
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0715
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0716
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0721
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0732
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0733
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0734
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0735
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0736
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0737
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0738
Y if rental or over 1K Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0739
Y if rental or over 1K Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0740
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0743
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0744
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0745
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0746
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0747
Y if rental or over 1K Y if rental or over 1K Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0748
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0749
Y if rental or over 1K Y if rental or over 1K Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0755
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0760
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0761
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0762
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0764
Y if rental or over 1K Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0765
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0766
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0767
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0769
Not Required Y if rental or over 1K Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0770
Not Required Not Required Not Required Not Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0776
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0779
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0780
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0781
Not Required Not Required Y if rental or over 1K Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0782
Not Required Not Required Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0783
Not Required Not Required Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0784
• Insulin pumps ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0787
Y if rental or over 1K Not Required Y if rental or over 1K Y if rental or over 1K Not Required Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0791
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0830
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0840
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0849
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0850
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0855
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0856
Not Required Not Required Y if rental or over 1K Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0860
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0870
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0880
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0890
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0900
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0910
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0911
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0912
Not Required Not Required Y if rental or over 1K Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0920
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0930
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0935
Not Required Not Required Y for purchases over 1K Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0936
Y if rental or over 1K Y if rental or over 1K Not Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0940
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0941
Not Required Not Required Y if rental or over 1K Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0942
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0944
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0945
Not Required Not Required Y if rental or over 1K Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0946
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0947
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0948
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0950
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0951
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0952
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0953
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0954
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0955
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0956
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0957
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0958
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0959
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0960
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0961
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0966
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0967
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0968
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0969
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0970
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0971
Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0973
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0974
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0978
Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0980
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0981
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0982
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0983
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0984
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0985
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0986
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0988
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0990
Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0992
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0994
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E0995
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1002
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1003
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1004
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1005
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1006
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1007
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1008
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1009
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1010
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1011
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1012
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1014
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1015
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1016
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1017
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1018
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1020
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1028
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1029
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1030
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1031
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1035
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1036
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1037
Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1038
Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1039
Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Not Required Y for purchases over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1050
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1060
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1070
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1083
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1084
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1085
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1086
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1087
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1088
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1089
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1090
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1092
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1093
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1100
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1110
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1130
Required Required Required Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1140
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1150
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1160
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1161
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1170
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1171
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1172
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1180
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1190
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1195
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1200
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1220
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1221
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1222
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1223
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1224
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1225
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1226
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1227
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1228
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1229
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1230
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1231
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1232
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1233
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1234
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1235
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1236
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1237
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1238
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1239
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1240
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1250
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1260
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1270
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1280
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1285
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1290
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1295
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1296
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1297
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1298
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1300
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1301
Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1310
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1352
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1372
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1399
Interferential stimulation Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1500
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1510
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1520
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1530
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1540
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1550
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1560
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1570
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1575
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1580
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1590
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1592
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1594
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1600
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1610
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1615
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1620
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1625
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1629
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1630
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1632
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1634
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1635
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1636
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1637
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1639
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1699
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1700
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1701
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1702
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1800
Y if rental or over 1K Not Required Y if rental or over 1K Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1801
Not Required Not Required Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1802
Not Required Not Required Y if rental or over 1K Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1803
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1804
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1805
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1806
treatment of joint stiffness and contractures unproven
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1807
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1808
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1810
Not Required Not Required Y if rental or over 1K Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1811
Not Required Not Required Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1812
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1813
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1814
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1815
Not Required Not Required Y if rental or over 1K Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1816
(e.g., joint active systems (JAS) devices)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1818
Not Required Not Required Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1820
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1821
forearm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1822
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1823
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1825
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1826
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1827
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1828
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1829
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1830
Not Required Not Required Y if rental or over 1K Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1831
E1832
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1832
E1841
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1840
Not Required Not Required Y if rental or over 1K Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1841
Subchondroplasty/Subchondral Calcium 0707T Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1902
Y if rental or over 1K Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E1905
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2000
Not Required Not Required Y if rental or over 1K Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2001
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2100
Y if rental or over 1K Not Required Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2101
Y if rental or over 1K Not Required Y if rental or over 1K Y if rental or over 1K Not Required Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2102
( , , , , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2103
( , , , , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2104
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2120
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2201
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2202
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2203
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2204
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2205
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2206
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2207
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2208
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2209
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2210
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2211
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2212
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2213
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2214
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2215
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2216
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2217
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2218
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2219
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2220
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2221
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2222
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2224
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2225
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2226
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2227
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2228
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2230
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2231
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2291
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2292
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2293
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2294
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2295
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2298
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2300
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2301
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2310
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2311
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2312
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2313
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2321
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2322
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2323
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2324
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2325
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2326
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2327
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2328
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2329
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2330
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2331
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2340
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2341
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2342
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2343
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2351
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2358
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2359
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2360
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2361
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2362
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2363
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2364
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2365
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2366
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2367
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2368
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2369
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2370
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2371
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2372
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2373
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2374
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2375
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2376
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2377
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2378
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2381
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2382
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2383
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2384
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2385
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2386
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2387
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2388
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2389
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2390
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2391
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2392
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2394
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2395
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2396
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2397
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2398
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2402
Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K Y for purchases over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2500
Y if rental or over 1K Not Required Y if rental or over 1K Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2502
Y if rental or over 1K Not Required Y if rental or over 1K Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2504
Y if rental or over 1K Not Required Y if rental or over 1K Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2506
Y if rental or over 1K Not Required Y if rental or over 1K Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2508
Y if rental or over 1K Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2510
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2511
Y if rental or over 1K Not Required Y if rental or over 1K Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2512
Y if rental or over 1K Not Required Y if rental or over 1K Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2513
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2599
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2601
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2602
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2603
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2604
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2605
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2606
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2607
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2608
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2609
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2610
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2611
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2612
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2613
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2614
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2615
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2616
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2617
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2619
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2620
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2621
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2622
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2623
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2624
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2625
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2626
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2627
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2628
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2629
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2630
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2631
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2632
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E2633
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E3000
Y if rental or over 1K Y if rental or over 1K Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E3200
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E8000
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E8001
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
E8002
Y if rental or over 1K Y if rental or over 1K Not Required Required Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0027
( , ), and repeat semen analysis ( ) may be separately reimbursed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0108
Diabetic Education ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0109
Diabetic Education ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0123
transplant or those with long-term
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0124
transplant or those with long-term
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0127
Routine Foot Care ( , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0141
steroid use
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0143
steroid use
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0144
• Women beginning in adolescence
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0145
• Women beginning in adolescence
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0147
who have been diagnosed with
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0148
who have been diagnosed with
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0151
• Physical Therapist
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0152
• Occupational Therapist
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0153
• Speech Therapist
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0155
• Medical Social Services
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0156
• Home Health Aide
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0159
effective therapy (e.g., physical therapy, , occupational therapy, , and speech
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0160
effective therapy (e.g., physical therapy, , occupational therapy, , and speech
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0161
therapy, ) maintenance program in the home setting. However, no coverage will be
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0162
• Registered Nurse (RN)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0219
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0235
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0237
• Respiratory Therapy
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0238
• Respiratory Therapy
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0239
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0245
CDPHP will not administer benefits for , , and (initial, follow-up and routine
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0246
CDPHP will not administer benefits for , , and (initial, follow-up and routine
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0247
Routine Foot Care ( , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0252
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0260
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0270
• Nutritional Counseling
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0276
Not Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0277
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0281
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0283
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0299
• Registered Nurse (RN)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0300
• Licensed Practical Nurse (LPN)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0308
Required Not Required Required Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0309
Required Not Required Required Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0320
• Tele-homecare
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0321
• Tele-homecare
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0322
• Tele-homecare
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0327
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0329
Modalities
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0339
Stereotactic body radiosurgery: 77373, 77435
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0340
Stereotactic body radiosurgery: 77373, 77435
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0341
Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0342
Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0343
Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0398
• Unattended (home-based) sleep testing
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0399
• Unattended (home-based) sleep testing
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0400
• Unattended (home-based) sleep testing
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0422
Intensive Cardiac Rehabilitation
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0423
Intensive Cardiac Rehabilitation
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0428
Not Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0429
Not Required Not Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0432
Allogeneic Hematopoietic Stem Cell 38205, 38240 Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0448
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0480
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0481
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0482
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0483
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0493
• Registered Nurse (RN)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0494
• Licensed Practical Nurse (LPN)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0495
• Registered Nurse (RN)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0496
• Licensed Practical Nurse (LPN)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0555
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0563
Stereotactic body radiosurgery: 77373, 77435
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G0659
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2035
• : Prenatal Screening
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2063
• : Testing for Diagnosis of Active or Latent
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2067
G2077, G2078, G2079, G2080, G2086, G2087, G2088, 96372, J0570, Q9991, Q9992
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2068
G2077, G2078, G2079, G2080, G2086, G2087, G2088, 96372, J0570, Q9991, Q9992
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2070
G2077, G2078, G2079, G2080, G2086, G2087, G2088, 96372, J0570, Q9991, Q9992
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2071
G2077, G2078, G2079, G2080, G2086, G2087, G2088, 96372, J0570, Q9991, Q9992
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2072
G2077, G2078, G2079, G2080, G2086, G2087, G2088, 96372, J0570, Q9991, Q9992
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2073
G2077, G2078, G2079, G2080, G2086, G2087, G2088, 96372, J0570, Q9991, Q9992
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2074
G2077, G2078, G2079, G2080, G2086, G2087, G2088, 96372, J0570, Q9991, Q9992
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2075
G2077, G2078, G2079, G2080, G2086, G2087, G2088, 96372, J0570, Q9991, Q9992
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2076
G2077, G2078, G2079, G2080, G2086, G2087, G2088, 96372, J0570, Q9991, Q9992
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2077
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2078
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2079
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2080
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2086
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2087
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2088
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2121
• : Laboratory Testing for the Diagnosis of
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2125
• : Urinary Tumor Markers for Bladder
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2127
• : Vectra DA Blood Test for Rheumatoid
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2130
• : ST2 Assay for Chronic Heart Failure
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G2150
• : Biomarkers for Myocardial Infarction and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G9143
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G9880
5 percent WL Achieved from baseline weight
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G9881
9 percent WL Achieved from baseline weight
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G9886
Behavioral counseling for diabetes prevention, in-person
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G9887
Behavioral counseling for diabetes prevention, distance
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G9888
Maintenance 5 percent WL from baseline in months 7-12
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G9890
No change to effective added codes , which are allowable under the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
G9891
No change to effective added codes , which are allowable under the
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H0002
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H0004
Other Licensed Practitioner (OLP)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H0015
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H0020
G2077, G2078, G2079, G2080, G2086, G2087, G2088, 96372, J0570, Q9991, Q9992
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H0033
G2077, G2078, G2079, G2080, G2086, G2087, G2088, 96372, J0570, Q9991, Q9992
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H0034
G2077, G2078, G2079, G2080, G2086, G2087, G2088, 96372, J0570, Q9991, Q9992
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H0035
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H0036
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H0038
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H0040
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H2011
Other Licensed Practitioner (OLP)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H2012
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H2013
Removed from Crisis Intervention Services (Crisis Residential
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H2014
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H2015
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H2017
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H2018
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H2019
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H2023
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
H2025
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0174
HCPCS code Leqembi
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0175
Kisunla
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0202
Multiple Sclerosis Non-preferred: Lemtrada ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0217
HCPCS
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0219
Nexviazyme ( ): 100mg vial for reconstitution
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0220
Availability Lumizyme ( & ): 50mg alglucosidase alfa as lyophilized powder in single dose vial
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0221
Availability Lumizyme ( & ): 50mg alglucosidase alfa as lyophilized powder in single dose vial
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0222
HCPCS: with positive genetics and known neuropathy
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0223
HCPCS Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0225
HCPCS: • A baseline Polyneuropathy disability (PND) score of IIIb or lower AND
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0248
HCPCS Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0256
HCPCS codes Prolastin C: ; Glassia: ; Aralast: ; Zemaira
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0257
HCPCS codes Prolastin C: ; Glassia: ; Aralast: ; Zemaira
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0491
HCPCS Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0517
Eosinophilic Asthma Preferred: Nucala ( ), Fasenra ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0570
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0604
equivalent or other form of administration other than an oral form. Prior to January 1, 2018 Sensipar (cinacalcet) met the definition
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0606
under 42 CFR 413.234(a) and was paid under the Part D benefit. A new injectable drug, Parsabiv® ( , etelcalcetide), that falls within
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0775
HCPCS Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0791
Adakveo (crizanlizumab) [HCPCS Code: ] is available as a 100-mg/10-mL intravenous infusion
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0881
HCPCS: • Anemia Due to Chemotherapy in Patients with Cancer
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0885
HCPCS: • Treatment of anemia due to chronic kidney disease (CKD) in patients on
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0896
HCPCS Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J0897
Bone resorption agents Non-preferred: Prolia ( ), Bildyos (Qxxxx), Conexxence ( ), Jubbonti ( ), Ospomyv ( ), Stoboclo
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1096
into lacrimal canaliculus and the drug Dextenza ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1203
Pombiliti ( ): 105 mg cipaglucosidase alfa-atga as lyophilized powder in single dose vial
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1230
Injectable methadone ( ) products are not approved for the outpatient treatment of opioid
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1301
Availability Radicava: 30 mg/100 mL solution for injection ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1302
J - Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1304
Qalsody: Injection 100 mg/15 mL (6.7 mg/mL) solution in a single-dose vial ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1305
345mg/2.3mL (150mg/mL) and 1,200mg/8mL (150mg/mL) solution
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1306
HCPCS Administration
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1411
HCPCS Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1426
HCPCS codes Exondys 51: ; Vyondys 53: ; Viltepso: ; Amondys 45
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1427
HCPCS codes Exondys 51: ; Vyondys 53: ; Viltepso: ; Amondys 45
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1428
HCPCS codes Exondys 51: ; Vyondys 53: ; Viltepso: ; Amondys 45
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1429
HCPCS codes Exondys 51: ; Vyondys 53: ; Viltepso: ; Amondys 45
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1442
Disorders/Biosimilars – Non-preferred: Neupogen , Granix , Releuko , Nypozi
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1447
Disorders/Biosimilars – Non-preferred: Neupogen , Granix , Releuko , Nypozi
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1448
HCPCS Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1449
Disorders/Biosimilars – Non-preferred: Udenyca , Ziextenzo , Stimufend , Fylnetra , Rolvedon , Ryzneuta
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1551
INJECTION, IMMUNE GLOBULIN (CUTAQUIG), 100MG
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1555
INJECTION, IMMUNE GLOBULIN (CUVITRU), 100 MG
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1558
INJECTION, IMMUNE GLOBULIN (XEMBIFY), 100 MG
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1559
INJECTION, IMMUNE GLOBULIN (HIZENTRA), 100 MG
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1561
INJECTION, IMMUNE GLOBULIN, (GAMUNEX-C/GAMMAKED), NON-LYOPHILIZED (E.G., LIQUID), 500 MG
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1562
INJECTION, IMMUNE GLOBULIN (VIVAGLOBIN), 100 MG
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1569
INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON-LYOPHILIZED, (E.G., LIQUID), 500 MG
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1575
INJECTION, IMMUNE GLOBULIN/HYALURONIDASE, (HYQVIA), 100 MG IMMUNEGLOBULIN
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J1823
Uplizna - inebilizumab-cdon (medical)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J2182
Eosinophilic Asthma Preferred: Nucala ( ), Fasenra ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J2323
Preferred: Tysabri ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J2326
HCPCS code (Spinraza)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J2506
Blood Preferred: Neulasta , Fulphila , Nyvepria
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J2781
HCPCS
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J2782
HCPCS
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J2786
Non-preferred: Cinqair ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J2802
HCPCS Code Nplate –
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J2860
HCPCS Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J2998
HCPCS Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J3241
HCPCS Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J3357
determined that more than 50% of all use is self-administered and claims will no longer be paid under Part B with a J code . Claims will
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J3393
HCPCS Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J3394
HCPCS Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J3398
HCPCS Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J3399
J – Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J3401
HCPCS Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J3489
Preferred: Zoledronic Acid ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J3490
HCPCS Code Prevymis: (no specific HCPCS Code)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J3590
Disorders/Biosimilars – Non-preferred: Neupogen , Granix , Releuko , Nypozi
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7170
HCPCS Codes Hemlibra
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7172
Hympavzi
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7173
Alhemo
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7174
Qfitlia
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7189
HCPCS codes (Novoseven RT), (Alprolix), (Idelvion), (Rebinyn), (Esperoct), (Eloctate)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7201
HCPCS codes (Novoseven RT), (Alprolix), (Idelvion), (Rebinyn), (Esperoct), (Eloctate)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7202
HCPCS codes (Novoseven RT), (Alprolix), (Idelvion), (Rebinyn), (Esperoct), (Eloctate)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7203
HCPCS codes (Novoseven RT), (Alprolix), (Idelvion), (Rebinyn), (Esperoct), (Eloctate)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7204
HCPCS codes (Novoseven RT), (Alprolix), (Idelvion), (Rebinyn), (Esperoct), (Eloctate)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7205
HCPCS codes (Novoseven RT), (Alprolix), (Idelvion), (Rebinyn), (Esperoct), (Eloctate)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7207
(Adynovate), (Jivi), (SevenFact)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7208
(Adynovate), (Jivi), (SevenFact)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7212
(Adynovate), (Jivi), (SevenFact)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7318
Non-preferred: Durolane: ( ); Genvisc 850: ( ); Supartz FX: ( ); Hymovis: ( ); Euflexxa
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7320
Non-preferred: Durolane: ( ); Genvisc 850: ( ); Supartz FX: ( ); Hymovis: ( ); Euflexxa
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7321
Non-preferred: Durolane: ( ); Genvisc 850: ( ); Supartz FX: ( ); Hymovis: ( ); Euflexxa
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7322
Non-preferred: Durolane: ( ); Genvisc 850: ( ); Supartz FX: ( ); Hymovis: ( ); Euflexxa
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7323
( ); Synvisc-One: ( ); Gelsyn-3: ( ); Trivisc: ( ); Triluron: ( ), Hyalgan ( ), Visco-3
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7324
Osteoarthritis Preferred: Gel-One ( ), Monovisc ( ) and Orthovisc ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7325
( ); Synvisc-One: ( ); Gelsyn-3: ( ); Trivisc: ( ); Triluron: ( ), Hyalgan ( ), Visco-3
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7326
Osteoarthritis Preferred: Gel-One ( ), Monovisc ( ) and Orthovisc ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7327
Osteoarthritis Preferred: Gel-One ( ), Monovisc ( ) and Orthovisc ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7328
( ); Synvisc-One: ( ); Gelsyn-3: ( ); Trivisc: ( ); Triluron: ( ), Hyalgan ( ), Visco-3
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7329
( ); Synvisc-One: ( ); Gelsyn-3: ( ); Trivisc: ( ); Triluron: ( ), Hyalgan ( ), Visco-3
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7330
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7331
( ), SynoJoint ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7332
( ); Synvisc-One: ( ); Gelsyn-3: ( ); Trivisc: ( ); Triluron: ( ), Hyalgan ( ), Visco-3
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7336
Availability Qutenza (capsaicin) 8% contains 179 mg per patch
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7352
J-Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7401
4/1/21 Removed termed code and replaced with new code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7402
Mometasone furoate sinus implant, 10 micrograms (Sinuva™)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7799
NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J7999
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J9035
Biosimilars Non-preferred: Avastin ( ), Alymsys ( ) Vegzelma ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J9311
Biosimilars Non-preferred: Rituxan ( ), Rituxan Hycela ( ), Riabni ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J9312
Biosimilars Non-preferred: Rituxan ( ), Rituxan Hycela ( ), Riabni ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J9333
HCPCS Code Rystiggo
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J9355
Biosimilars Non-preferred: Herceptin ( ), Herceptin Hylecta ( ), Ogivri ( ), Herzuma ( ), Ontruzant
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J9356
Biosimilars Non-preferred: Herceptin ( ), Herceptin Hylecta ( ), Ogivri ( ), Herzuma ( ), Ontruzant
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J9361
longer acting
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J9376
HCPCS Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
J9381
HCPCS Code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0001
• Standard wheelchair rental ( - )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0007
• Standard wheelchair rental ( - )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0553
codes and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0554
codes and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0606
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0607
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0608
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0609
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0800
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0801
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0806
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0808
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0826
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0831
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0835
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0836
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0850
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0858
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0860
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0861
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0862
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K0903
2/1/2020 Removed termed code and added code for shoe
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K1001
Removed termed code and replaced with new code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K1002
Removed termed code and replaced it with new code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K1013
1/1/2024 Replaced termed code with new code in Select
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K1015
date of policy for this Removed termed code and replaced with new code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K1016
Removed termed code and replaced it with new code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K1018
Removed termed code and replaced it with new code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K1020
Removed termed code and replaced it with new code
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K1023
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K1027
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K1028
Removed termed codes and and replaced them
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K1029
Removed termed codes and and replaced them
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K1030
Contractility modulation generator - external Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K1031
Removed termed codes , , and and replaced
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K1032
Removed termed codes , , and and replaced
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
K1033
Removed termed codes , , and and replaced
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L0456
• The following orthotic codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L0464
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1007
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1200
• Scoliosis jacket/Thoracic Lumbar Sacral Orthoses (TLSO) ( , , ) when
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1210
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1300
• Scoliosis jacket/Thoracic Lumbar Sacral Orthoses (TLSO) ( , , ) when
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1310
• Scoliosis jacket/Thoracic Lumbar Sacral Orthoses (TLSO) ( , , ) when
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1499
Suit Therapy (i.e., Theratogs, TheraSuit, Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1832
• - Jace Tri-brace
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1845
• - Bledsoe brace
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1852
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1900
• Ankle foot orthotic (AFO) codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1902
• Ankle foot orthotic (AFO) codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1904
• Ankle foot orthotic (AFO) codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1906
• Ankle foot orthotic (AFO) codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1907
• Ankle foot orthotic (AFO) codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1910
• Ankle foot orthotic (AFO) codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1920
• Ankle foot orthotic (AFO) codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1930
L2106, L2108, L2112, L2114, L2116, L2200, L2210, L2220, L2230, L2232, L2240,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1932
L2106, L2108, L2112, L2114, L2116, L2200, L2210, L2220, L2230, L2232, L2240,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1940
L2106, L2108, L2112, L2114, L2116, L2200, L2210, L2220, L2230, L2232, L2240,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1945
L2106, L2108, L2112, L2114, L2116, L2200, L2210, L2220, L2230, L2232, L2240,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1950
L2106, L2108, L2112, L2114, L2116, L2200, L2210, L2220, L2230, L2232, L2240,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1951
L2106, L2108, L2112, L2114, L2116, L2200, L2210, L2220, L2230, L2232, L2240,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1960
L2106, L2108, L2112, L2114, L2116, L2200, L2210, L2220, L2230, L2232, L2240,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1970
L2106, L2108, L2112, L2114, L2116, L2200, L2210, L2220, L2230, L2232, L2240,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1971
L2106, L2108, L2112, L2114, L2116, L2200, L2210, L2220, L2230, L2232, L2240,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1980
L2106, L2108, L2112, L2114, L2116, L2200, L2210, L2220, L2230, L2232, L2240,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L1990
L2106, L2108, L2112, L2114, L2116, L2200, L2210, L2220, L2230, L2232, L2240,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2106
L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, L2335,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2108
L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, L2335,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2112
L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, L2335,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2114
L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, L2335,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2116
L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, L2335,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2200
L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, L2335,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2210
L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, L2335,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2220
L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, L2335,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2230
L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, L2335,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2232
L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, L2335,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2240
L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, L2335,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2250
L2340, L2350, L2360, L2370,L2375, L4002, L4090, L4205, L4210, L4350, L4360,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2260
L2340, L2350, L2360, L2370,L2375, L4002, L4090, L4205, L4210, L4350, L4360,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2265
L2340, L2350, L2360, L2370,L2375, L4002, L4090, L4205, L4210, L4350, L4360,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2270
L2340, L2350, L2360, L2370,L2375, L4002, L4090, L4205, L4210, L4350, L4360,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2275
L2340, L2350, L2360, L2370,L2375, L4002, L4090, L4205, L4210, L4350, L4360,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2280
L2340, L2350, L2360, L2370,L2375, L4002, L4090, L4205, L4210, L4350, L4360,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2300
L2340, L2350, L2360, L2370,L2375, L4002, L4090, L4205, L4210, L4350, L4360,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2310
L2340, L2350, L2360, L2370,L2375, L4002, L4090, L4205, L4210, L4350, L4360,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2320
L2340, L2350, L2360, L2370,L2375, L4002, L4090, L4205, L4210, L4350, L4360,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2330
L2340, L2350, L2360, L2370,L2375, L4002, L4090, L4205, L4210, L4350, L4360,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2335
L2340, L2350, L2360, L2370,L2375, L4002, L4090, L4205, L4210, L4350, L4360,
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2340
L4361, L4370, L4386, L4387, L4392, L4394, L4396, L4397, L4398, L4631
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2350
L4361, L4370, L4386, L4387, L4392, L4394, L4396, L4397, L4398, L4631
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2360
L4361, L4370, L4386, L4387, L4392, L4394, L4396, L4397, L4398, L4631
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2370
L4361, L4370, L4386, L4387, L4392, L4394, L4396, L4397, L4398, L4631
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2375
L4361, L4370, L4386, L4387, L4392, L4394, L4396, L4397, L4398, L4631
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2755
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L2840
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L3000
• CDPHP will provide coverage for custom foot orthotics ( - ) in lieu of
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L3030
• CDPHP will provide coverage for custom foot orthotics ( - ) in lieu of
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L3041
Determination: Physical Medicine and Rehabilitation ( ), Accessed 5/1/06
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L3161
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L3760
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L3960
• – Airplane splint/shoulder
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L3984
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L4002
L4361, L4370, L4386, L4387, L4392, L4394, L4396, L4397, L4398, L4631
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L4090
L4361, L4370, L4386, L4387, L4392, L4394, L4396, L4397, L4398, L4631
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L4205
L4361, L4370, L4386, L4387, L4392, L4394, L4396, L4397, L4398, L4631
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L4210
L4361, L4370, L4386, L4387, L4392, L4394, L4396, L4397, L4398, L4631
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L4350
L4361, L4370, L4386, L4387, L4392, L4394, L4396, L4397, L4398, L4631
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L4360
L4361, L4370, L4386, L4387, L4392, L4394, L4396, L4397, L4398, L4631
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L4361
• L3960 – Airplane splint/shoulder
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L4370
• L3960 – Airplane splint/shoulder
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L4386
• L3960 – Airplane splint/shoulder
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L4387
• L3960 – Airplane splint/shoulder
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L4392
• L3960 – Airplane splint/shoulder
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L4394
• L3960 – Airplane splint/shoulder
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L4396
• L3960 – Airplane splint/shoulder
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L4397
• L3960 – Airplane splint/shoulder
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L4398
• L3960 – Airplane splint/shoulder
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L4631
• L3960 – Airplane splint/shoulder
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5020
• The following orthotic codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5301
• The following orthotic codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5321
• The following orthotic codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5460
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5585
• The following orthotic codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5611
• The following orthotic codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5618
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5620
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5624
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5632
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5636
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5643
L5845, L5856, L5964, L5968, L5973, L5981, L5987, L5988, L6110, L6721, L6884
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5649
L5845, L5856, L5964, L5968, L5973, L5981, L5987, L5988, L6110, L6721, L6884
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5651
L5845, L5856, L5964, L5968, L5973, L5981, L5987, L5988, L6110, L6721, L6884
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5657
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5673
L5845, L5856, L5964, L5968, L5973, L5981, L5987, L5988, L6110, L6721, L6884
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5681
L5845, L5856, L5964, L5968, L5973, L5981, L5987, L5988, L6110, L6721, L6884
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5700
L5845, L5856, L5964, L5968, L5973, L5981, L5987, L5988, L6110, L6721, L6884
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5701
L5845, L5856, L5964, L5968, L5973, L5981, L5987, L5988, L6110, L6721, L6884
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5705
L5845, L5856, L5964, L5968, L5973, L5981, L5987, L5988, L6110, L6721, L6884
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5781
L5845, L5856, L5964, L5968, L5973, L5981, L5987, L5988, L6110, L6721, L6884
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5828
L5845, L5856, L5964, L5968, L5973, L5981, L5987, L5988, L6110, L6721, L6884
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5840
L5845, L5856, L5964, L5968, L5973, L5981, L5987, L5988, L6110, L6721, L6884
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5845
& MEDICAL SUPPLIES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5856
& MEDICAL SUPPLIES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5910
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5925
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5940
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5964
& MEDICAL SUPPLIES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5968
& MEDICAL SUPPLIES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5969
B. A microprocessor-controlled ankle-foot with power assist ( AND )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5972
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5973
& MEDICAL SUPPLIES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5981
& MEDICAL SUPPLIES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5987
& MEDICAL SUPPLIES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L5988
& MEDICAL SUPPLIES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6000
Upper limb prostheses (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6010
Upper limb prostheses (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6020
Upper limb prostheses (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6034
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6035
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6036
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6038
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6039
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6050
Upper limb prostheses (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6055
Upper limb prostheses (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6100
Upper limb prostheses (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6110
& MEDICAL SUPPLIES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6120
Upper limb prostheses (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6130
Upper limb prostheses (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6200
L6550):
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6205
L6550):
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6250
L6550):
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6300
L6550):
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6310
L6550):
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6320
L6550):
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6350
L6550):
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6360
L6550):
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6370
L6550):
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6400
L6550):
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6450
L6550):
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6500
L6550):
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6550
)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6680
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6698
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6721
& MEDICAL SUPPLIES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L6884
& MEDICAL SUPPLIES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L7400
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L7520
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L7700
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L7900
Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L7902
Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8015
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8035
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8435
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8605
Required Not Required Not Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8607
Required Not Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8614
Cochlear device, includes all internal and external components
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8615
Replacement components of cochlear implant device/system (code range)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8619
Code Description
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8621
Replacement batteries used with cochlear implant device/system (code range)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8624
Code Description
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8625
External recharging system for battery for use with cochlear implant or auditory
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8627
Cochlear implant, external speech processor, component, replacement
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8628
Cochlear implant, external controller component, replacement
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8629
Transmitting coil and cable, integrated, for use with cochlear implant device
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8680
A device ( - , - ) that is used to electrically stimulate a member’s spinal
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8683
A device ( - , - ) that is used to electrically stimulate a member’s spinal
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8685
A device ( - , - ) that is used to electrically stimulate a member’s spinal
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8689
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8690
Auditory osseointegrated device, includes all internal and external components
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8691
Auditory osseointegrated device, external sound processor, excludes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8693
Auditory osseointegrated device, abutment, any length, replacement only
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8694
Auditory osseointegrated device, transducer/actuator, replacement only, each
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8699
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8701
Required Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
L8702
Required Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
M0075
Not Required Not Required Not Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
M0076
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
M0300
Required Not Required Not Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
M2027
Neoplasms and removed archived policies: BCR - ABL 1
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
M2037
• : Genetic Testing for Familial Cutaneous
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
M2039
for PGT in accordance with criteria outlined in policy, –
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
M2062
Testing and Genetic Testing for Acute Myeloid Leukemia
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
M2066
Genetic Cancer Susceptibility Using Next Generation
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
M2084
• : Genetic Testing for Mental Health
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
M2109
6/14/2022 Removed obsolete policy Molecular Panel Testing of
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
M2111
• : Multigene Expression Assay for Predicting
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
M2178
3/15/2022 New policy added to the list of tests reviewed by Avalon
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
M2179
• : Prenatal Screening (Genetic)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
M2180
• : Genetic Markers for Assessing Risk of
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
M2182
3/1/2024 New policy added: Genomic Testing for Hematopoietic
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
P3000
cervical dysplasia or cervical cancer
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
P3001
cervical dysplasia or cervical cancer
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
P4177
Journal of Clinical Endocrinology and Metabolism. Vol. 82, No. 12, Dec. 1998, pp
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
P4188
3. Crain, J.; Wilmer, K.; Steuerwald, N.; Young, E.: Transactions of the Sixteenth Annual
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q0091
• Sexually active women beginning in
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q2026
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q2041
chemoimmunotherapy
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q2042
second or later relapse
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q2043
ICD10 diagnosis codes
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q2053
precursor acute lymphoblastic leukemia (ALL)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q2054
lymphoma), high-grade B-cell lymphoma, primary
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q2055
immunotherapy inhibitor, and an anti-CD38 monoclonal antibody
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q2056
immunotherapy immunomodulatory agent, and are refractory to
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q2058
Breyanzi® (lisocabtagene 2021 CD19-directed genetically Adult patients with large B-cell lymphoma (LBCL),
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4100
Skin substitute, not otherwise specified
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4101
Apligraf, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4102
Oasis wound matrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4103
(E/I) Oasis burn matrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4104
(E/I) Integra bilayer matrix wound dressing (BMWD), per square cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4105
Integra dermal regeneration template (DRT) or Integra Omnigraft dermal
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4106
Dermagraft, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4107
GRAFTJACKET, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4108
Integra matrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4110
(E/I) PriMatrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4111
(E/I) GammaGraft, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4112
(E/I) Cymetra, injectable, 1 cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4113
(E/I) GRAFTJACKET XPRESS, injectable, 1 cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4114
(E/I) Integra flowable wound matrix, injectable, 1 cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4115
(E/I) AlloSkin, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4116
AlloDerm, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4117
(E/I) HYALOMATRIX, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4118
(E/I) MatriStem micromatrix, 1 mg
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4121
TheraSkin, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4122
DermACELL, DermACELL AWM or DermACELL AWM Porous, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4123
(E/I) AlloSkin RT, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4124
(E/I) OASIS ultra tri-layer wound matrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4125
(E/I) ArthroFlex, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4126
(E/I) MemoDerm, DermaSpan, TranZgraft or InteguPly, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4127
(E/I) Talymed, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4128
FlexHD, AllopatchHD, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4130
(E/I) Strattice TM, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4132
Grafix Core and GrafixPL Core, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4133
Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4134
(E/I) HMatrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4135
(E/I) Mediskin, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4136
(E/I) E-Z Derm, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4137
(E/I) AmnioExcel, AmnioExcel Plus or BioDExcel, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4138
(E/I) BioDFence DryFlex, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4139
(E/I) AmnioMatrix or BioDMatrix, injectable, 1 cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4140
(E/I) BioDFence, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4141
(E/I) AlloSkin AC, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4142
(E/I) XCM biologic tissue matrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4143
(E/I) Repriza, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4145
(E/I) EpiFix, injectable, 1 mg
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4146
(E/I) Tensix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4147
(E/I) Architect, Architect PX, or Architect FX, extracellular matrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4148
(E/I) Neox Cord 1K, Neox Cord RT, or Clarix Cord 1K, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4149
(E/I) Excellagen, 0.1 cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4150
(E/I) AlloWrap DS or dry, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4151
AmnioBand or Guardian, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4152
(E/I) DermaPure, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4153
(E/I) Dermavest and Plurivest, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4154
Biovance, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4155
(E/I) Neox Flo or Clarix Flo, 1 mg
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4156
(E/I) Neox 100 or Clarix 100, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4157
(E/I) Revitalon, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4158
(E/I) Kerecis Omega3, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4159
(E/I) Affinity, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4160
(E/I) NuShield, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4161
(E/I) Bio-ConneKt wound matrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4162
(E/I) WoundEx Flow, BioSkin Flow, 0.5 cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4163
(E/I) WoundEx, BioSkin, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4164
(E/I) Helicoll, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4165
(E/I) Keramatrix or Kerasorb, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4166
(E/I) Cytal, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4167
(E/I) Truskin, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4168
(E/I) AmnioBand, 1 mg
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4169
(E/I) Artacent wound, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4170
(E/I) Cygnus, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4171
(E/I) Interfyl, 1 mg
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4172
• Removed termed code from Exclusions
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4173
(E/I) PalinGen or PalinGen Xplus, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4174
(E/I) PalinGen or ProMatrX, 0.36 mg per 0.25 cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4175
(E/I) Miroderm, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4176
(E/I) Neopatch or therion, per square centimeter
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4177
(E/I) FlowerAmnioFlo, 0.1 cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4178
(E/I) FlowerAmnioPatch, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4179
(E/I) FlowerDerm, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4180
(E/I) Revita, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4181
(E/I) Amnio Wound, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4182
Transcyte, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4183
(E/I) Surgigraft, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4184
(E/I) Cellesta or Cellesta Duo, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4185
(E/I) Cellesta Flowable Amnion (25 mg per cc); per 0.5 cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4186
Epifix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4187
Epicord, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4188
(E/I) AmnioArmor, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4189
(E/I) Artacent AC, 1 mg
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4190
(E/I) Artacent AC, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4191
(E/I) Restorigin, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4192
(E/I) Restorigin, 1 cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4193
(E/I) Coll-e-Derm, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4194
(E/I) Novachor, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4195
(E/I) PuraPly, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4196
(E/I) PuraPly AM, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4197
(E/I) PuraPly XT, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4198
(E/I) Genesis Amniotic Membrane, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4199
(E/I) Cygnus matrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4200
(E/I) SkinTE, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4201
(E/I) Matrion, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4202
(E/I) Keroxx (2.5 g/cc), 1cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4203
(E/I) Derma-Gide, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4204
(E/I) XWRAP, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4205
(E/I) Membrane Graft or Membrane Wrap, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4206
(E/I) Fluid Flow or Fluid GF, 1 cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4208
(E/I) Novafix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4209
(E/I) SurGraft, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4211
(E/I) Amnion Bio or axoBioMembrane, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4212
(E/I) AlloGen, per cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4213
(E/I) Ascent, 0.5 mg
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4214
(E/I) Cellesta Cord per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4215
(E/I) Axolotl Ambient or Axolotl Cryo, 0.1 mg
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4216
(E/I) Artacent Cord, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4217
(E/I) WoundFix, BioWound, WoundFix Plus, BioWound Plus, WoundFix Xplus or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4218
(E/I) SurgiCORD, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4219
(E/I) SurgiGRAFT-DUAL, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4220
(E/I) BellaCell HD or Surederm, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4221
(E/I) Amnio Wrap2, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4222
(E/I) ProgenaMatrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4224
(E/I) Human Health Factor 10 Amniotic Patch (HHF10-P), per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4225
(E/I) AmnioBind, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4226
(E/I) MyOwn Skin, includes harvesting and preparation procedures, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4227
(E/I) AmnioCore TM, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4229
(E/I) Cogenex Amniotic Membrane, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4230
(E/I) Cogenex Flowable Amnion, per 0.5 cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4231
(E/I) Corplex P, per cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4232
(E/I) Corplex, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4233
(E/I) SurFactor or NuDyn, per 0.5 cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4234
(E/I) XCellerate, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4235
(E/I) AMNIOREPAIR or AltiPly, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4236
(E/I) CarePATCH, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4237
(E/I) Cryo-Cord, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4238
(E/I) Derm-Maxx, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4239
(E/I) Amnio-Maxx or Amnio-Maxx Lite, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4240
(E/I) CoreCyte, for topical use only, per 0.5 cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4241
(E/I) PolyCyte, for topical use only, per 0.5 cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4242
(E/I) AmnioCyte Plus, per 0.5 cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4245
(E/I) AmnioText, per cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4246
(E/I) CoreText or ProText, per cc
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4247
(E/I) Amniotext patch, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4248
(E/I) Dermacyte Amniotic Membrane Allograft, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4249
(E/I) AMNIPLY, for topical use only, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4250
(E/I) AmnioAmp-MP, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4251
(E/I) VIM per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4252
(E/I) Vendaje, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4253
(E/I) Zenith Amniotic Membrane, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4254
(E/I) Novafix DL, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4255
(E/I) REGUaRD, for topical use only, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4256
(E/I) MLG-Complete, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4257
(E/I) Relese, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4258
(E/I) Enverse, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4259
(E/I) Celera Dual Layer or Celera Dual Membrane, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4260
(E/I) Signature APatch, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4261
(E/I) TAG, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4262
(E/I) Dual Layer Impax Membrane, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4263
(E/I) SurGraft TL, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4264
(E/I) Cocoon Membrane, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4265
(E/I) NeoStim TL, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4266
(E/I) NeoStim Membrane, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4267
(E/I) NeoStim DL, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4268
(E/I) SurGraft FT, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4269
(E/I) SurGraft XT, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4270
(E/I) Complete SL, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4271
(E/I) Complete FT, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4272
(E/I) Esano A, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4273
(E/I) Esano AAA, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4274
(E/I) Esano AC, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4275
(E/I) Esano ACA, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4276
(E/I) ORION, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4278
(E/I) EPEFFEICT, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4279
(E/I) Vendaje AC, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4280
(E/I) Xcell Amnio Matrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4281
(E/I) Barrera SL or Barrera DL, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4282
(E/I) Cygnus Dual, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4283
(E/I) Biovance Tri-Layer or Biovance 3L, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4284
(E/I) DermaBind SL, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4285
(E/I) NuDYN DL or NuDYN DL MESH, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4286
(E/I) NuDYN SL or NuDYN SLW, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4287
(E/I) DermaBind DL, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4288
(E/I) DermaBind CH, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4289
(E/I) RevoShield+ Amniotic Barrier, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4290
(E/I) Membrane Wrap-Hydro, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4291
(E/I) Lamellas XT, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4292
(E/I) Lamellas, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4293
(E/I) Acesso DL, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4294
(E/I) Amnio Quad-Core, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4295
(E/I) Amnio Tri-Core Amniotic, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4296
(E/I) Rebound Matrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4297
(E/I) Emerge Matrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4298
(E/I) AmniCore Pro, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4299
(E/I) AmniCore Pro+, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4300
(E/I) Acesso TL, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4301
(E/I) Activate Matrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4302
(E/I) Complete ACA, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4303
(E/I) Complete AA, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4304
(E/I) GRAFIX PLUS, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4305
(E/I) American Amnion AC Tri-Layer, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4306
(E/I) American Amnion AC, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4307
(E/I) American Amnion, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4308
(E/I) Sanopellis, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4309
(E/I) VIA Matrix, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4310
(E/I) Procenta, per 100 mg
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4311
(E/I) Acesso, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4312
(E/I) Acesso AC, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4313
(E/I) DermaBind FM, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4314
(E/I) Reeva FT, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4315
(E/I) RegeneLink Amniotic Membrane Allograft, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4316
(E/I) AmchoPlast, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4317
(E/I) VitoGraft, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4318
(E/I) E-Graft, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4319
(E/I) SanoGraft, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4320
(E/I) PelloGraft, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4321
(E/I) RenoGraft, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4322
(E/I) CaregraFT, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4323
(E/I) alloPLY, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4324
(E/I) AmnioTX, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4325
(E/I) ACApatch, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4326
(E/I) WoundPlus, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4327
(E/I) DuoAmnion, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4328
(E/I) MOST, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4329
(E/I) Singlay, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4330
(E/I) TOTAL, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4331
(E/I) Axolotl Graft, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4332
(E/I) Axolotl DualGraft, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4333
(E/I) ArdeoGraft, per sq cm
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4334
(E/I) AmnioPlast 1, per sq cm (effective 10/01/24)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4335
(E/I) AmnioPlast 2, per sq cm (effective 10/01/24)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4336
(E/I) Artacent C, per sq cm (effective 10/01/24)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4337
(E/I) Artacent Trident, per sq cm (effective 10/01/24)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4338
(E/I) Artacent Velos, per sq cm (effective 10/01/24)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4339
(E/I) Artacent Vericlen, per sq cm (effective 10/01/24)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4340
(E/I) SimpliGraft, per sq cm (effective 10/01/24)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4341
(E/I) SimpliMax, per sq cm (effective 10/01/24)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4342
(E/I) TheraMend, per sq cm (effective 10/01/24)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4343
(E/I) Dermacyte AC Matrix Amniotic Membrane Allograft, per sq cm (effective 10/01/24)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4344
(E/I) Tri-Membrane Wrap, per sq cm (effective 10/01/24)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4345
(E/I) Matrix HD Allograft Dermis, per sq cm (effective 10/01/24)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4346
(E/I) Shelter DM Matrix, per sq cm (effective 01/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4347
(E/I) Rampart DL Matrix, per sq cm (effective 01/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4348
(E/I) Sentry SL Matrix, per sq cm (effective 01/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4349
(E/I) Mantle DL Matrix, per sq cm (effective 01/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4350
(E/I) Palisade DM Matrix, per sq cm (effective 01/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4351
(E/I) Enclose TL Matrix, per sq cm (effective 01/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4352
(E/I) Overlay SL Matrix, per sq cm (effective 01/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4353
(E/I) Xceed TL Matrix, per sq cm (effective 01/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4354
(E/I) Palingen dual-layer membrane, per square centimeter (effective 04/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4355
(E/I) Abiomend xplus membrane and abiomend xplus hydromembrane, per square
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4356
(E/I) Abiomend membrane and abiomend hydromembrane, per square centimeter
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4357
(E/I) Xwrap plus, per square centimeter (effective 04/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4358
(E/I) Xwrap dual, per square centimeter (effective 04/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4359
(E/I) Choriply, per square centimeter (effective 04/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4360
(E/I) Amchoplast fd, per square centimeter (effective 04/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4361
(E/I) Epixpress, per square centimeter (effective 04/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4362
(E/I) Cygnus disk, per square centimeter (effective 04/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4363
(E/I) Amnio burgeon membrane and hydromembrane, per square centimeter (effective
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4364
(E/I) Amnio burgeon xplus membrane and xplus hydromembrane, per square centimeter
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4365
(E/I) Amnio burgeon dual-layer membrane, per square centimeter (effective 04/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4366
(E/I) Dual layer amnio burgeon x-membrane, per square centimeter (effective 04/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4367
(E/I) Amniocore sl, per square centimeter (effective 04/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4368
(E/I) AmchoThick, per sq cm (effective 07/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4369
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4370
(E/I) AeroGuard, per sq cm (effective 07/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4371
(E/I) NeoGuard, per sq cm (effective 07/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4372
(E/I) AmchoPlast EXCEL, per sq cm (effective 07/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4373
(E/I) Membrane Wrap-Lite, per sq cm (effective 07/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4375
(E/I) duoGRAFT AC, per sq cm (effective 07/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4376
(E/I) Duograft AA, per sq cm (effective 07/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4377
(E/I) triGRAFT FT, per sq cm (effective 07/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4378
(E/I) Renew FT Matrix, per sq cm (effective 07/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4379
(E/I) AmnioDefend FT Matrix, per sq cm (effective 07/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4380
(E/I) AdvoGraft One, per sq cm (effective 07/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4382
(E/I) AdvoGraft Dual, per sq cm (effective 07/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4383
(E/I) Axolotl Graft Ultra, per sq cm (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4384
(E/I) Axolotl DualGraft Ultra, per sq cm (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4385
(E/I) Apollo FT, per sq cm (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4386
(E/I) Acesso TrifACA, per sq cm (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4387
(E/I) NeoThelium FT, per sq cm (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4388
(E/I) NeoThelium 4L, per sq cm (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4389
(E/I) NeoThelium 4L Plus, per sq cm (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4390
(E/I) Ascendion, per sq cm (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4391
(E/I) AmnioPlast Double, per sq cm (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4392
(E/I) GRAFIX Duo, per sq cm (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4393
(E/I) SurGraft AC, per sq cm (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4394
(E/I) SurGraft ACA, per sq cm (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4395
(E/I) Acelagraft, per sq cm (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4396
(E/I) Natalin, per sq cm (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4397
(E/I) Summit AAA, per sq cm (effective 10/01/25)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4398
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4399
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4400
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4401
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4402
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4403
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4404
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4405
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4406
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4407
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4408
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4409
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4410
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4411
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4412
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4413
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4414
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4415
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4416
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4417
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q4420
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5101
Blood Preferred: Zarxio , Nivestym
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5106
HCPCS: • Reduction of allogeneic red blood cell transfusions in patients undergoing
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5107
Preferred: Mvasi ( ), Zirabev ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5108
Blood Preferred: Neulasta , Fulphila , Nyvepria
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5110
Blood Preferred: Zarxio , Nivestym
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5111
Disorders/Biosimilars – Non-preferred: Udenyca , Ziextenzo , Stimufend , Fylnetra , Rolvedon , Ryzneuta
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5112
( ), Hercessi ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5113
Biosimilars Non-preferred: Herceptin ( ), Herceptin Hylecta ( ), Ogivri ( ), Herzuma ( ), Ontruzant
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5114
Biosimilars Non-preferred: Herceptin ( ), Herceptin Hylecta ( ), Ogivri ( ), Herzuma ( ), Ontruzant
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5115
Preferred: Ruxience ( ), Truxima ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5116
Preferred: Trazimera ( ), Kanjinti ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5117
Preferred: Trazimera ( ), Kanjinti ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5118
Preferred: Mvasi ( ), Zirabev ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5119
Preferred: Ruxience ( ), Truxima ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5120
Disorders/Biosimilars – Non-preferred: Udenyca , Ziextenzo , Stimufend , Fylnetra , Rolvedon , Ryzneuta
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5122
Blood Preferred: Neulasta , Fulphila , Nyvepria
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5123
Biosimilars Non-preferred: Rituxan ( ), Rituxan Hycela ( ), Riabni ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5125
Disorders/Biosimilars – Non-preferred: Neupogen , Granix , Releuko , Nypozi
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5126
Biosimilars Non-preferred: Avastin ( ), Alymsys ( ) Vegzelma ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5127
Disorders/Biosimilars – Non-preferred: Udenyca , Ziextenzo , Stimufend , Fylnetra , Rolvedon , Ryzneuta
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5129
Biosimilars Non-preferred: Avastin ( ), Alymsys ( ) Vegzelma ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5130
Disorders/Biosimilars – Non-preferred: Udenyca , Ziextenzo , Stimufend , Fylnetra , Rolvedon , Ryzneuta
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5136
Bone resorption agents Non-preferred: Prolia ( ), Bildyos (Qxxxx), Conexxence ( ), Jubbonti ( ), Ospomyv ( ), Stoboclo
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5146
( ), Hercessi ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5157
( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5158
Bone resorption agents Non-preferred: Prolia ( ), Bildyos (Qxxxx), Conexxence ( ), Jubbonti ( ), Ospomyv ( ), Stoboclo
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5159
Bone resorption agents Non-preferred: Prolia ( ), Bildyos (Qxxxx), Conexxence ( ), Jubbonti ( ), Ospomyv ( ), Stoboclo
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q5160
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q9991
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
Q9992
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S0002
non-invasive tests. Am J Surg. 2020 Nov 25: -9610(20) -4
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S0140
phase 3 trial. Lancet. 2020 Sep 12;396( ):759-769. doi: 10.1016/ -6736(20) -X. Epub
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S0189
• Testopel is billed with code and will require PA review. Testopel will
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S0207
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S0390
Routine Foot Care ( , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S0515
Contact lenses –
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S0741
https://www.jvascsurg.org/article/ -5214(11) -2/pdf
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S0800
)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S0810
)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S1030
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S1031
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S1034
( , , , , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S1035
( , , , , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S1036
( , , , , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S1037
( , , , , , , , , , , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S1040
Cranial Remolding Orthosis ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S1091
Stent, non-coronary, temporary, with delivery system (Propel™)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S1474
multicentre, phase 3 trial. Lancet Neurol. 2021 Apr;20(4):284-293. doi: 10.1016/ -4422(21) -6
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2050
2019 Sep 17. pii: -1161(19) -3
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2053
Transplantation of small intestine, and liver allografts
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2054
Transplantation of multivisceral organs
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2065
Simultaneous pancreas kidney transplantation
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2066
S2067 S2068
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2067
19316 Mastopexy (breast lift) to treat
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2068
19316 Mastopexy (breast lift) to treat
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2080
•Laser-assisted uvulopalatoplasty (LAUP) ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2083
Adjustment of gastric band diameter via subcutaneous port by injection or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2102
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2117
Subtalar arthroereisis for the treatment of Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2118
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2120
Not Required Not Required Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2142
Cord blood-derived stem-cell transplantation, allogeneic
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2150
Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2235
Implantation of auditory brainstem implant
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2348
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2350
Required through Health Help Required through Health Help Not Required Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2405
review. Eur Urol Focus. 2021 Mar 1: -4569(21) -0
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S2666
Therapy. Transplant Cell Ther. 2024 Sep 20: -6367(24) -1
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S3800
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S3840
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S3841
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S3842
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S3844
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S3845
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S3846
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S3849
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S3850
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S3852
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S3853
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S3854
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S3861
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S3865
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S3866
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S3870
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S3890
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S3900
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S4013
• Gamete intrafallopian transfer (GIFT) and follicle aspiration ( , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S4014
• Zygote intrafallopian transfer (ZIFT) ( , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S5125
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S5126
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S5130
• Personal Care Aide Level I (Homemaker/Housekeeper)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S5150
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S5151
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S5160
• Personal emergency response system
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S5161
• Personal emergency response system
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S5165
7/1/24 Removed codes for EMods, VMods, and AAT ( , , and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S8035
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S8037
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S8042
Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help Required through Health Help
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S8080
Not Required Not Required Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S8092
Not Required Required Not Required Not Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S8130
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S8131
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S8420
The following codes will be allowed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S8428
The following codes will be allowed
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S8940
Hippotherapy ( ), as scientific evidence is insufficient to determine the effects of this
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S8948
Low-level or high-level laser therapy Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S8990
(NMN) Physical or manipulative therapy performed for maintenance rather than
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9001
Uterine activity monitoring; home setting Covered when performed during an
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9055
Required Not Required Required Required Not Required Not Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9090
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9110
Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K Y if rental or over 1K
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9122
• Home Health Aide
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9123
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9124
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9127
• Medical Social Services
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9128
• Speech Therapist
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9129
• Occupational Therapist
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9131
• Physical Therapist
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9208
inpatient hospitalization only
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9349
Tocolytic infusion therapy; home setting Experimental, investigational, or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9465
Diabetic Education ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9470
• Nutritional Counseling
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9472
Removed from the list of Exclusions
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9473
such as
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9480
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9484
Crisis Intervention (CI), including Crisis Residential Services
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9485
Crisis Intervention (CI), including Crisis Residential Services
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9500
Home infusion therapy (HCPCS)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9501
Home infusion therapy (HCPCS)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9502
Home infusion therapy (HCPCS)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9503
Home infusion therapy (HCPCS)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9504
Home infusion therapy (HCPCS)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9960
wheelchair van and/or private or commercial air transportation ( – , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9961
wheelchair van and/or private or commercial air transportation ( – , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9988
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9990
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9991
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9992
Required Not Required Not Required Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9994
Required Not Required Not Required Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
S9996
Not Required Not Required Not Required Required Not Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T1000
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T1001
• : RN Supervisory Visit
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T1002
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T1003
Not Required Not Required Required Not Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T1014
• Tele-homecare
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T1015
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T1019
• Personal Care Aide Level II
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T1020
• Personal Care Aide Level II
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T1021
• Home Health Aide
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T1030
• Registered Nurse (RN)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T1031
• Licensed Practical Nurse (LPN)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T2013
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T2015
• : Prescription Medication and Illicit Drug
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T2017
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T2019
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T2020
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T2024
Assessment/Plan of Care Development: (Billed to
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T2028
)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T2034
PROCEDURE CODES
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
T2039
7/1/24 Removed codes for EMods, VMods, and AAT ( , , and
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2020
Frames –
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2025
• Deluxe frame ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2100
Single vision lenses –
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2121
Single vision lenses –
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2200
Lens: Bifocal lenses –
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2221
Lens: Bifocal lenses –
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2300
Trifocal lenses –
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2321
Trifocal lenses –
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2410
Variable asphericity lenses –
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2430
Variable asphericity lenses –
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2500
Contact lenses –
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2520
Corneal liquid bandage encompasses the use of both therapeutic soft contact lenses (
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2521
) and rigid gas permeable scleral contact lenses ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2522
) and rigid gas permeable scleral contact lenses ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2523
) and rigid gas permeable scleral contact lenses ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2530
) and rigid gas permeable scleral contact lenses ( , , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2531
Contact lenses –
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2623
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2626
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2627
)
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2628
Required Required Required Required Required Required
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2630
Intraocular lenses –
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2632
Intraocular lenses –
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2702
• Deluxe lens feature ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2744
• Tinted lenses ( , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2745
• Tinted lenses ( , )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2750
• Antireflective coating ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2755
• U-V lens ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2760
• Scratch-resistant coating ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2761
• Mirror coating ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2762
• Polarization ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2780
• Oversized lenses ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2781
Progressive lens ( ) are considered an acceptable alternative to standard bifocals or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2782
• High index glass or plastic ( , ) lenses for indications such as lightweight or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2783
• High index glass or plastic ( , ) lenses for indications such as lightweight or
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2784
Lenses made of polycarbonate ( ) are covered for enrollees with functional vision in only
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2786
• Specialty occupational multifocal lenses ( )
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2787
Intraocular lenses –
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2788
Intraocular lenses –
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS
V2790
Amniotic membrane for surgical reconstruction, per procedure
2026-07-012022-10-0197%
[PDF] CDPHP Policies List - AWS